Social identities and mental well-being in autistic adults

Self-reported masking in sexual minority and heterosexual autistic adults

Masking can include suppressing or concealing certain behaviors to appear "non-autistic" and is one response to the excess social stressors of being a neurominority in a neurotypical-majority society. It is important to understand how persons who are multiply marginalized (e.g. an autistic person assigned female sex at birth who is bisexual), who experience multiple layers of excess social stressors, may face additional pressures to conceal their authentic selves. Autistic persons may be more likely than neurotypical persons to identify with a sexual minority orientation, such as asexual, bisexual, gay or pansexual. To advance our understanding of how marginalized identities may be associated with masking, we examined self-reported masking using the Camouflaging Autistic Traits Questionnaire in a sample of autistic adults (N = 462). After matching participants for assigned sex at birth and age, and after controlling for these effects in modeling, we found that sexual minority autistic adults reported significantly higher levels of masking relative to heterosexual autistic adults. We situate these findings within literatures on masking, minority stress, and stigma.Lay AbstractMasking can include hiding certain behaviors to appear "non-autistic." Masking is one response to the stress of being autistic in a non-autistic world. Being autistic is only one part of someone's identity, though. Other parts of a person's identity include things like a person's sexual orientation. Autistic people are more likely than non-autistic people to have a sexual orientation other than heterosexual, like asexual, bisexual, gay, or pansexual. People who are both autistic and a sexual minority may experience social stress because of different pressures from society. These different pressures may mean sexual minority autistic adults feel pressured to social camouflage more than heterosexual autistic adults. Thus, we compared masking in sexual minority autistic and heterosexual autistic adults. In the statistical models, we controlled for two other factors that may impact masking: sex assigned at birth and age. We found that sexual minority autistic adults reported significantly higher levels of masking relative to heterosexual autistic adults. We discuss how these findings fit within previous research on masking and minority stress.

A systematic review: Which psycho-social-environmental factors do autistic students identify as being important for positive experiences in mainstream secondary school?

Mainstream secondary school can be a challenging environment for autistic students, in part due to social and sensory factors. Research to date has focussed on identifying the negative aspects of school experience; however, few studies have identified factors that promote positive experiences. We take a neuro-affirmative approach when exploring how schools can support autistic students, informed by both the social and the human rights models of disability. We conducted a systematic review of qualitative studies in which autistic adolescents and adults identified factors that related to positive experiences in mainstream secondary school. We identified 117 relevant studies and 36 met inclusion criteria. Through thematic synthesis, we developed overarching themes: 'Understanding and Acceptance', 'Environments that suit me' and 'Agency to meet my needs', with additional subthemes. This study identified that agency, understanding and acceptance by both staff and peers, as well as access to engaging activities, were key factors in creating a positive and supportive environment for autistic students. Adaptation to both the social and sensory contexts were important to meet the needs of autistic students. The findings suggest that policy and practice should focus on creating a positive environment in schools for autistic students, in addition to addressing current challenges.Lay abstractResearch has shown that many autistic students do not thrive in mainstream secondary schools. Often studies focus on the challenges autistic people face rather than what supports thriving. We reviewed published articles, exploring what factors helped autistic people create a positive experience in school from their own perspective. We identified 36 studies and analysed the direct quotes made by autistic adolescents and adults in these studies. Factors important for positive experience included the autistic student feeling understood and accepted by adults and peers in school, being able to shape sensory and social environments in ways that suited them and accessing engaging activities. This review highlighted ways in which schools can become more inclusive and positive environments for autistic students.

Exploring Lived Experiences of Receiving a Diagnosis of Autism in Adulthood: A Systematic Review

Background

Growing numbers of adults are seeking and receiving autism diagnoses. This systematic review collates, evaluates, and synthesizes evidence on the lived experiences of receiving a diagnosis of autism in adulthood.

Methods

A keyword-search was performed on six databases, with results systematically screened to identify relevant studies. Data extracted from the studies were analyzed using thematic synthesis.

Results

Initial searches produced 12,785 articles, 26 of which were included and subjected to thematic synthesis. We identified two meta-themes: Constantly Struggling, related to (1) events that prompted diagnosis, (2) struggling to get a diagnosis, (3) haphazard supports, (4) costs of a late diagnosis, and (5) stigma; and Revelation, involving (1) emotional reactions to diagnosis, and (2) forging an autistic identity.

Discussion

While diagnosis can grant understanding, acceptance, and community, autistic adults continue to struggle with stigma, regret, and inadequate support post-diagnosis. Understanding the first-person perspectives of those who have acquired an autism diagnosis in adulthood is vital in developing sensitive and effective assessment and support services for adults.

The Lived Experience of Autistic Adults in Employment: A Systematic Search and Synthesis

Background

Employment is a critical factor contributing to the well-being and quality of life of autistic people of working age. Historically, research has tended to focus on interventions and employment-related outcomes, typically generated without the input of autistic workers. Interventions often work to help the autistic worker fit into the working environment rather than it being adjusted for the autistic worker. However, a growing body of research reflects autistic workers' experiences of employment with consideration given to how the workplace should change to reflect the differences of this historically marginalized group.

Methods

This study is a systematic analysis of existing research that focuses on and prioritizes autistic workers' experiences of employment. Our analysis draws on the social relational model of disability (SRMD), an approach increasingly applied in contexts of autism and employment. We systematically searched five journal databases, resulting in 34 articles that reflect the lived experience of autistic people in employment.

Results

We identified four themes through narrative synthesis: Navigating Social Demands; the Disabling Nature of the Work Environment designed for neurotypical workers; Adapt to Me; and Understanding, Knowledge, and Acceptance. The results draw on the SRMD, revealing nuances to inclusionary and exclusionary employment for the autistic workforce.

Conclusion

Our findings encourage the prioritization of the voice of autistic workers when designing working environments. They also function as a critique of the traditional approaches that placed employers, managers, and human resource professionals as the dominant agents of decision-making. In these traditional practices, the burden of making employment viable was on the worker, rather than the employer. The results of this study framed through the SRMD allowed for enhanced understanding of the barriers and new insights into how to improve the employment experience for autistic adults.

Autism Transition to Adulthood Groups (ATAG): protocol for a feasibility RCT of a new peer-group intervention to promote successful transition to adulthood for autistic young people

INTRODUCTION

Autism is a lifelong neurodevelopmental condition diagnosed on the basis of differences in social communication, interaction and repetitive behaviours, including sensory sensitivities. Autistic individuals without intellectual disabilities often face barriers to positive adult outcomes and are at high risk for poor health, including mental health issues, which could be mitigated by improving well-being. Young people should receive support to increase their well-being during the transition to adulthood, when social and family support often reduces. This is the protocol for a feasibility randomised controlled trial (RCT) of an online peer-group intervention, 'Understanding You, Discovering You' (UYDY). Objectives included assessing recruitment and retention rates, acceptability of procedures, characterising usual care, assessing the acceptability of UYDY and care as usual (CAU) and calculating outcome measure variances for a full trial.

METHODS AND ANALYSIS

This two-arm parallel feasibility RCT includes a nested qualitative evaluation. Seventy participants aged 16-25 years old with a clinical autism diagnosis will be randomised on a 1:1 basis to UYDY or CAU. Exclusion criteria include risk of harm to self or others, receipt of postdiagnostic support in the past 12 months, and literacy levels such that the written session materials are not accessible. UYDY, a 6-week online peer-group intervention, will cover topics such as understanding autism, problem-solving and accessing services, and is facilitated by an autistic person and social care professionals. The main outcomes from the feasibility trial will be collecting data on (1) recruitment and retention rates; (2) the acceptability of randomisation and outcome measurement procedures; (3) CAU accessed by participants; (4) acceptability of the interventions; (5) clinical outcome measure variances (see below). See the Statistical methods section below for how this will be assessed in the current study. Clinical outcomes will be measured at baseline, and 8, 16 and 24 weeks post-randomisation. The primary clinical outcome is well-being, assessed using the Warwick Edinburgh Mental Wellbeing Scale. Secondary clinical outcomes include autism social identification, quality of life, social support and loneliness. Adverse events will be monitored and reported. Carer impact will also be measured. Participants will be recruited from England and Wales via charities and NHS services. Qualitative interviews will be conducted to explore the acceptability of trial participation including randomisation and the interventions.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the HRA and NHS REC (23/WA/0113). Informed consent will be collected from all participants (see online supplemental material for an example consent form). Results will inform the design of a full RCT and will be disseminated through peer-reviewed journals, conferences, and stakeholder events.

TRIAL REGISTRATION NUMBER

ISRCTN10513626.

Suicidal Thoughts and Behaviors in People on the Autism Spectrum

PURPOSE OF REVIEW

This review synthesizes recent research on suicidal thoughts and behaviors among autistic individuals. We present literature on risk and protective factors, risk assessment, intervention, and crisis services, and recommendations for future research.

RECENT FINDINGS

Literature on this topic has grown substantially in recent years. Areas of advancement include improved understanding of risk factors (e.g., Interpersonal Theory of Suicide constructs, autistic burnout, mental health conditions, cognitive factors, diagnosis timing, emotion dysregulation), screening, assessment, acute-care services, and suicide-specific psychosocial treatments (e.g., safety planning, dialectical behavior therapy). Gaps include protective factors, impact of intersectional identities, and tailored approaches to screening, assessment, and intervention. Heightened awareness of suicide risk in autistic individuals has led to increased understanding of why autistic individuals think about and attempt suicide and the strategies used to identify and reduce suicide risk. We recommend community-partnered, multi-faceted, and strength-based approaches to inform tailored prevention and intervention efforts.

Resilience in the face of neurodivergence: A scoping review of resilience and factors promoting positive outcomes

Neurodivergent individuals, including a range of conditions impacting neurological function, are at an increased likelihood of poor life outcomes, such as in functional adaptation, mental health, and well-being. Yet, many live meaningful and fulfilling lives. Resilience may provide some explanation for the heterogeneity in outcomes observed in neurodivergent populations. We conducted a scoping review embedded in a neurodiversity-affirmative approach to provide an understanding of resilience in neurodivergent populations. A total of 176 articles were included in this review and were synthesized using a two-phased process. First, findings were synthesized narratively to examine how resilience has been conceptualized and explored in neurodivergent populations. Second, to identify the bio-psycho-social factors important for resilience in neurodivergent individuals, we converted concepts identified in articles to the nomenclature of the World Health Organizations' International Classification of Functioning, Disability and Health (ICF) using a standardized linking process. We find considerable variability in how resilience is conceptualized and measured in neurodivergent populations. We identified 83 unique ICF categories representing resilience factors, of which only 20 appeared in more than 5% of the articles. Identified ICF categories highlight the importance of support systems such as families and friends, community participation and acceptance, and individual capabilities for resilience.

Examination of the Potential Moderating Role of Psychological Wellbeing in the Relationship Between Depression and Thoughts of Self-Harm in Autistic Adolescents and Adults: A Two-Year Longitudinal Study

PURPOSE

Autistic people have a significantly increased risk of death by suicide relative to the general population. In non-autistic samples, psychological wellbeing has been shown to moderate the relationship between depression and suicidal thoughts and behavior. Thoughts of self-harm may provide a useful indicator of suicidal risk. In this longitudinal study we examined (a) the potential role for psychological wellbeing to moderate the relationship between depressive symptoms and thoughts of self-harm and (b) the contribution of autistic traits to thoughts of self-harm.

METHODS

Participants were 209 autistic adolescents and adults aged 15 to 80 years (Mage = 34.20, SD = 15.38 years).

RESULTS

At both baseline and 2-year follow-up, 35% of participants reported recent thoughts of self-harm. Wellbeing was associated with autistic traits (r = - .350 to - 0.404) and depression (r = - .480 to - 0.759). Thoughts of self-harm were positively associated with autistic traits and depression (r = .242 to 0.659), and negatively associated with wellbeing (r = - .287 to - 0.609). Controlling for baseline thoughts of self-harm, depression (β = 0.254, p = .001) and autistic traits (β = 0.162, p = .007) significantly predicted thoughts of self-harm at 2-year follow-up.

CONCLUSION

Despite a lack of support for the hypothesis that wellbeing would moderate the relationship between depression and thoughts of self-harm, correlational data demonstrated significant associations between wellbeing and both depression and thoughts of self-harm. Future research considering psychological wellbeing as a potential protective factor for self-harm in autistic people is warranted.

Examining an integrated path model of psychological and sociocultural predictors of camouflaging in autistic adults

LAY ABSTRACT

Many autistic people use strategies known as 'camouflaging' to change how noticeable their autistic traits are in social situations. Previous research suggests that camouflaging is largely motivated by psychological and social factors. However, most studies so far have only looked at a few psychosocial factors related to camouflaging. In this study, we explored a model that included several individual psychological factors (such as fear of being negatively judged, self-esteem and autistic identity) and broader social and cultural factors (such as perceived stigma, negative life events, cultural emphasis on conformity and desire to fit in or stand out). We surveyed 225 autistic adults aged 18-77 years online. Our findings showed that several sociocultural factors were indirectly linked to camouflaging through individual psychological factors. Fear of being negatively judged emerged as a strong predictor of camouflaging. Specifically, autistic adults who perceived greater stigma, felt greater pressure to conform, had a lesser desire to stand out and a greater desire to fit in tended to experience a greater fear of being negatively judged and reported more camouflaging. In addition, those who experienced more negative life events were more likely to engage in camouflaging. Our study identifies key psychological and social factors as potential targets for social change. Our findings emphasise that our societies need to shift away from stigmatising attitudes towards accepting and including autistic people, which could reduce the pressure on autistic individuals to camouflage in social situations.

Exploring the mediating effect of camouflaging and the moderating effect of autistic identity on the relationship between autistic traits and mental wellbeing

Mental health difficulties are prevalent among autistic adults. Camouflaging (behaving differently to fit in) may be a mechanism by which autistic traits and mental health difficulties relate to each other, but little research has considered the role of different facets of camouflaging. Additionally, autistic identity might buffer against camouflaging and mental health difficulties. This research aims to explore the mediating effects of camouflaging behaviours on the relationship between autistic traits and both positive and negative mental wellbeing, as well as how autistic identity might moderate the relationship between autistic traits and camouflaging, and also mental health. Data were available for 627 autistic adults, recruited through volunteer databases and social media. Participants completed measures of autistic traits, anxiety, depression, positive wellbeing, camouflaging behaviours (compensating for difficulties, masking, and assimilating/putting on an act) and autistic identity. Mediation and moderated mediation models were tested, applying 95% bootstrapped CIs (10,000 resamples) and including age, gender and diagnosis as covariates. There were no significant direct effects between autistic traits and mental wellbeing. Assimilation was a significant mediator of all mental wellbeing measures, and compensation was a significant mediator of positive wellbeing only. Autistic identity was not a significant moderator. Assimilation and compensation should be considered when offering psychological interventions to support mental wellbeing of autistic people. Additional research into external drivers of camouflaging (e.g. stigma) and mechanisms by which camouflaging impacts mental wellbeing, such as autonomy, authenticity, skill mastery and community, may identify other areas of support. Concurrently, societal change is necessary to reduce the need to camouflage.

"A perfect storm": Autistic experiences of menopause and midlife

LAY ABSTRACT

Previous studies report that menopause can be a very difficult transition for some autistic people. This study focuses on how autistic people experience menopause and what support and information might help them. Autistic Community Research Associates played an important role in the research and co-authored this article. We held four focus groups and eight interviews online with 24 autistic participants who lived in either Canada (n = 13) or the United Kingdom (n = 11). We analysed participant conversations using a method called reflexive thematic analysis. Participants described many intense challenges during menopause. Four themes and eight subthemes were identified across participant groups: (1) Complexity, multiplicity and intensity of symptoms (0 subthemes); (2) Life experience and adversity converging at midlife (three subthemes); (3) The importance of knowledge and connection (two subthemes); and (4) Barriers to support and care (three subthemes). The experiences of our participants may not be the same as other autistic people, and the study could have been more inclusive of diverse autistic groups. However, hearing about the experiences of others may provide reassurance to autistic people who struggle with menopause and let them know they are not alone.

Assessment of Social Connection among Autistic and Non-Autistic Adults: A Proof of Concept Study for the Connections with Others Scales

BACKGROUND

A gap exists in measures available to assess levels of motivation, desire, and value associated with connecting with others. Moreover, few social connection scales have been developed with a goal of including autistic individuals in the sample to create a measure that has utility across neurodiverse populations. This study aims to develop a measure to assess different facets of social connection that is valid among both autistic and non-autistic adults.

METHODS

The sample consisted of 200 participants recruited online. Participants completed an initial set of 35 items. Exploratory factor analyses and confirmatory factor analyses were performed. Four-factor models were produced by the EFAs.

RESULTS

Item reduction resulted in the development of two 8-item scales: the Connections with Others Scale (CWOS) intended for the general population and the CWOS-Autistic Version (CWOS-AV) intended for autistic populations (CWOS-AV). Autistic participants had significantly greater motivation/desire to connect with others compared to non-autistic participants (t(195) = 3.39; p < 0.001).

CONCLUSIONS

These measures will allow for greater ability to assess the motivation to connect with others, resulting in improved ability to produce research that clarifies theories and describes psychological phenomena.

Autistic Traits and Psychosocial Predictors of Depressive Symptoms

Higher rates of depression and of depressed mood are associated with autistic traits, and both are associated with social interaction factors, such as social self-efficacy, social motivation and loneliness. This study examined whether these social factors explain the association between autistic traits and depression. 658 participants (527 women) completed an online survey with measures of autistic traits (AQ), social self-efficacy (Social Self-Efficacy Scale), social motivation (Social Striving Assessment Scale), loneliness (UCLA Loneliness Scale) and depressive symptoms (Beck Depression Inventory-II). A mediation analysis found the relationship between autistic traits and depressive symptoms was fully mediated by the other three factors (β[indirect] = .005, z = 2.63, p < .01; β[direct] = .05, z = 1.58, p > .05), forming a pathway from autistic traits, to social self-efficacy, to social motivation, to loneliness and finally to depressive symptoms. These results suggest that targeting social self-efficacy may break this pathway and disrupt this relationship. Interventions targeting supporting positive social interaction should be considered.

Autistic identity: A systematic review of quantitative research

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

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.

Meaningful Social Inclusion and Mental Well-Being Among Autistic Adolescents and Emerging Adults: Protocol for a Community-Based Mixed Methods Study

BACKGROUND

In the United States, autistic people face high rates of co-occurring mental illnesses and premature death due to self-harm, which are indicators of threats to mental well-being. Social inclusion may enhance mental well-being and resilience among autistic people. According to Simplican and colleague's (2015) model of social inclusion for people with intellectual and developmental disabilities, social inclusion is an interaction between community participation and interpersonal relationships. There is limited research on social inclusion that includes the integration of interpersonal relationships and community participation among autistic people or the impact of social inclusion on the well-being of autistic people. Additionally, little evidence exists regarding how autistic people prefer to be included in the community or form interpersonal relationships.

OBJECTIVE

The long-term objective of this project is to improve social inclusion factors to support the mental well-being of autistic people. This protocol describes a community-based, mixed methods pilot study to develop a definition of meaningful social inclusion for autistic people and to understand the relationship between meaningful social inclusion and mental well-being among autistic adolescents and emerging adults.

METHODS

The project uses a community-based, sequential mixed methods design with a formative phase (Phase 1) that informs a survey phase (Phase 2) and concludes with a process evaluation of the community engagement process (Phase 3). During Phase 1, we will recruit 10 community partners (autistic adults and stakeholders) and conduct sharing sessions to cocreate a definition of meaningful social inclusion and a survey of meaningful social inclusion and well-being. During Phase 2, we will recruit 200 participants (100 autistic adolescents and emerging adults and 100 caregivers) to complete the survey. We will examine whether meaningful social inclusion predicts well-being given sociodemographic factors using ordered logistic regression, with well-being categorized as low, medium, and high. During Phase 3, the community partners from Phase 1 will complete a survey on their experiences with the project.

RESULTS

Ethics approval was obtained for this project in March 2023. We have recruited community partners and started the Phase 1 focus groups as of September 2023. Phase 2 and Phase 3 have not yet started. We expect to complete this study by March 2025.

CONCLUSIONS

Using a community-based, mixed methods approach, we intended to develop a definition of meaningful social inclusion for autistic people and understand the role meaningful social inclusion plays in the well-being of autistic people.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52658.

Self-Report Measurement of Well-Being in Autistic Adults: Psychometric Properties of the PERMA Profiler

Background

Studies of positive psychology and emotional well-being have broadened our understanding of mental health. However, mental health research involving autistic adults has been largely deficit-focused. Few studies have examined well-being using established positive psychological frameworks.

Methods

This study examined the psychometric characteristics of the PERMA Profiler, a 23-item questionnaire that measures well-being across five subscales (Positive emotion, Engagement, Relationships, Meaning, and Accomplishment), in a sample of 517 autistic adults ages 18-84 years (M = 39.5, standard deviation [SD] = 13.3). Reliability (internal consistency), structural validity (via confirmatory factor analysis including bifactor modeling), and concurrent validity were examined.

Results

The PERMA Profiler mean (SD) well-being score was 5.4 (SD = 1.7), which is notably lower than the mean of 7.0 previously found in nonautistic samples. Subscale scores were highest for Engagement (M = 6.8; SD = 1.9), followed by Accomplishment (M = 5.6; SD = 2.2), Relationships (M = 5.2; SD = 2.6), Meaning (M = 5.2; SD = 2.7), and Positive emotion (M = 5.0; SD = 2.4). Factor analyses revealed strong psychometrics (Cronbach's α = 0.93; Comparative Fit Index = 0.94; Tucker-Lewis Index = 0.97; root mean square error of approximation = 0.08; standardized root mean residual = 0.05) and superior fit of the bifactor model, supporting a general factor for conceptualizing well-being as opposed to a five-factor model. PERMA well-being and subscale scores were significantly correlated (p < 0.001) with mental health conditions and life satisfaction.

Conclusion

These findings support use of an adapted version of the PERMA Profiler in mental health research to evaluate well-being among autistic adults. Similar to studies with nonautistic populations, the Engagement measure may not capture the experiences of the autistic population and further refinement is needed. Follow-up research should represent a more diverse autistic population, collaborate with autistic coinvestigators, and explore potential correlates of well-being (such as social stigma) while using the PERMA Profiler.

Autistic adults' experiences of managing wellbeing and implications for social prescribing

Autistic people demonstrate poor outcomes on objective measures of wellbeing, yet research centring lived experience provides a more nuanced picture. There is growing support for person-centred, holistic and community approaches to enhancing wellbeing for autistic people. Social prescribing may be one such approach. This qualitative study explored the concept of wellbeing for autistic adults - including barriers and self-management - and the implications of this for modifying social prescribing. It involved semi-structured interviews with 21 autistic adults in the UK. Reflexive thematic analysis of the data supports research suggesting that self-determination may underlie many aspects of wellbeing for autistic people. The COVID-19 pandemic provided new opportunities to develop wellbeing strategies but also had negative impacts. Social prescribing could promote self-determination by signposting autistic people to peer support opportunities building on intrinsic interests.

Applications of identity-based theories to understand the impact of stigma and camouflaging on mental health outcomes for autistic people

Autistic people have long been conceptualized from a deficit-based model of disability, but recent self-advocates and scholars have asserted the importance of recognizing autism as both a disability and an important part of a person's social identity. The autistic identity is subject to specific stigma and stressors beyond everyday discrimination and prejudice, which can have many downstream implications on mental health and well-being. Prior research on camouflaging has explained both quantitatively and qualitatively how autistic people conform to norms and mask their autistic traits to better fit in with non-autistic societal standards. Given this paradigm shift in understanding autistic peoples' lived experiences, researchers must also begin to reshape the theories guiding their work in order to improve diagnosis, intervention, and supports. This review examines the extant research on identity-related stigma and camouflaging and their subsequent impacts on mental health outcomes in autism. A model is proposed integrating identity-based theories-specifically the social model of disability, social identity theory, and minority stress model-to explain relationships across research areas and better explain the experiences of autistic people. We discuss how identity-based theories can be applied in autism research to better understand the impacts of stigma and camouflaging on autistic peoples' lived experiences and reduce disparities in their mental health outcomes.

"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.

"Peas in a pod": Oral History Reflections on Autistic Identity in Family and Community by Late-Diagnosed Adults

In this paper, we report on a participatory oral history study documenting the lives of late-diagnosed autistic adults in Australia. We interviewed 26 autistic adults about their life history and the impact of late diagnosis. All were diagnosed after the age of 35, growing up in an era when autism was not well known. Using reflexive thematic analysis, we uncovered a rich body of reflections on shared Autistic identity and identified three major themes within that data set: 'conceptualising the Autistic family', 'creating Autistic community', and 'contesting Autistic identity'. Overall, the study provides insights into the active creation of shared Autistic identity and the importance of Autistic community to these late-diagnosed autistic adults.

Consensus statements on optimal adult post-autism diagnosis support and services: Delphi process following a UK survey of autistic adults, relatives and clinicians

LAY ABSTRACT

Research has identified types of support helpful to autistic people, for example, physical and mental health interventions, psycho-education, peer support, developing positive identities and affiliation with social groups. However, accessing suitable post-autism diagnosis support and services is extremely difficult. We asked autistic adults, relatives and clinicians about their experiences of receiving and delivering post-autism diagnosis support/services. In Stage 1, 343 autistic adults and 45 relatives completed a survey. They answered questions about their experiences of UK autism post-diagnosis support/services for adults within 12 months after receiving a diagnosis. Thirty-five clinicians completed a similar survey. Just over half of adults and relatives said there was a follow-up appointment or discussion about support after diagnosis. Fewer than 40% received any support/services in 12 months after diagnosis. We used information from the surveys to create 11 statements describing characteristics of appropriate adult post-autism diagnosis support/services. In Stage 2, we asked clinicians for their views on the statements - they agreed with all of them. For example, those adults are offered an additional follow-up meeting after diagnosis and have access to mental and physical health services. We shared results with autistic adults, relatives and clinicians at two events. Some autistic adults, relatives and clinicians were positive about post-autism diagnosis support/services. However, they described many areas for improvement. The study findings can be used to define, develop and improve the types of adult post-diagnosis support services.

A systematic review of predictors of suicidal thoughts and behaviors among autistic adults: Making the case for the role of social connection as a protective factor

Autistic adults are a high-risk population for suicidal thoughts and behaviors (STBs). Accordingly, this systematic review aims to review the prevalence of STBs among autistic adults, review the risk and protective factors for STBs in autistic adults, and formulate a disorder-specific conceptualization of risk in this population. We systematically searched PsycINFO and Google Scholar for all studies published prior to March 28th, 2022. We included empirical articles focused on autistic adults, ages 18 years and older, reporting on suicide-related outcomes. In total, 45 peer-reviewed empirical articles were included in the current systematic review. The most frequently studied factors in relation to suicide risk among autistic adults were interpersonal constructs (42.4% of total studies looking at risk/protective factors) and depressive symptoms (36.4% of total studies looking at risk/protective factors). We conclude by summarize two key content areas: exploring social and interpersonal constructs and better understanding the role of depressive symptoms in autism. As researchers continue to explore STBs among autistic adults, it will be necessary to addressing the overreliance on autistic symptoms instead of autism diagnoses, measurement issues of STBs, and a need for treatment adaptations.

'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.

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

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

Lay abstract

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

Five Ways Providers Can Improve Mental Healthcare for Autistic Adults: A Review of Mental Healthcare Use, Barriers to Care, and Evidence-Based Recommendations

PURPOSE OF REVIEW

We reviewed the literature from 2017 to 2022 on autistic adults' use of mental healthcare and barriers to care. To encourage immediate improvement in mental healthcare, we provide five strategies mental health providers can use to better care for autistic adults.

RECENT FINDINGS

Most autistic adults use mental healthcare and use it more often than non-autistic adults. Autistic adults' experiences with mental healthcare are characterized by (1) lack of providers knowledgeable about autism, (2) use of treatments that may not be accommodating to individual needs, and (3) difficulty navigating the complex healthcare system. These barriers contribute to prevalent unmet needs for mental healthcare. Autistic adults use mental healthcare frequently but have unmet mental health needs. As necessary systemic changes develop, providers can begin immediately to better care for autistic adults by learning about their needs and taking personalized care approaches to meet those needs.

Brief Report: Does Autistic Community Connectedness Moderate the Relationship Between Masking and Wellbeing?

Background

Masking involves blending in or covering a stigmatized identity, to avoid discrimination and to "pass" within society. Autistic people often report masking, both intentionally and unintentionally, to get by in social situations. Autistic people who report high rates of masking also tend to experience poorer mental health. It is important we understand whether there are variables that can protect against the negative effects of masking. One such potential variable is autistic community connectedness (ACC)-being part of and belonging to the autistic community. Past research suggests there are benefits for autistic people socially connecting with other autistic people. We investigated whether ACC could moderate the relationship between masking and wellbeing.

Methods

One hundred ninety-six autistic people completed an online survey including measures of ACC, masking, and mental wellbeing. We used moderation analysis to test whether ACC acted as a buffer between masking and wellbeing.

Results

Higher self-reported masking related to poorer mental wellbeing. Higher ACC related to more positive wellbeing. Higher ACC correlated with more masking. However, there was no interaction effect, and ACC did not moderate the relationship between masking and wellbeing.

Conclusions

Although ACC did relate to more positive mental wellbeing overall, it did not moderate the negative relationship between masking and wellbeing. If masking relates to the prejudice faced by autistic people, those with greater attachment to the autistic community may also be more aware of discrimination against their community. Furthermore, autistic people who are more connected might experience a higher salience of masking when moving between autistic and nonautistic settings. Tackling prejudice toward autistic people is critical in helping to reduce the negative effects associated with masking, and we must endeavor to change perceptions and increase inclusion of autistic people.

Representativeness of autistic samples in studies recruiting through social media

Survey-based research with recruitment through online channels is a convenient way to obtain large samples and has recently been increasingly used in autism research. However, sampling from online channels may be associated with a high risk of sampling bias causing findings not to be generalizable to the autism population. Here we examined autism studies that have sampled on social media for markers of sampling bias. Most samples showed one or more indicators of sampling bias, in the form of reversed sex ratio, higher employment rates, higher education level, lower fraction of individuals with intellectual disability, and later age of diagnosis than would be expected when comparing with for example population study results from published research. Findings from many of the included studies are therefore difficult to generalize to the broader autism population. Suggestions for how research strategies may be adapted to address some of the problems are discussed. LAY SUMMARY: Online surveys offer a convenient way to recruit large numbers of participants for autism research. However, the resulting samples may not fully reflect the autism population. Here we investigated the samples of 36 autism studies that recruited participants online and found that the demographic composition tended to deviate from what has been reported about the autism population in previous research. The results may thus not be generalizable to autism in general.

Self-reported COVID-19 vaccination acceptance and hesitancy among autistic adults

Identifying factors associated with COVID-19 vaccination acceptance among vulnerable groups, including autistic individuals, can increase vaccination rates and support public health. The purpose of this study was to determine differences among autistic adults who reported COVID-19 vaccination acceptance from those who did not. In this study we describe COVID-19 vaccination status and self-reported preferences among autistic adults and identify related factors. Vaccine accepters were more likely to report increased loneliness during COVID-19, lived in more populous counties (p = 0.02), and lived in counties won by President Biden in the 2020 US presidential election (p < 0.001). Positive correlations were found between desire to protect others, concern about contracting COVID-19, and trusting vaccine safety (p < 0.001). Concern about vaccine safety was common among the vaccine hesitant, while lack of concern about COVID-19 overall was not. Identifying health promotion strategies based on self-reported, lived experiences about COVID-19 among vulnerable groups is key for public health impact.

Transdiagnostic research and the neurodiversity paradigm: commentary on the transdiagnostic revolution in neurodevelopmental disorders by Astle et al

In their comprehensive and articulate paper on the Transdiagnostic Revolution in Neurodevelopmental Disorders, Astle, Holmes, Kievit and Gathercole (2021) 'consider how well current classifications of neurodevelopmental disorders serve our understanding'. They examine the lack of mapping between clinical diagnoses such as ADHD or autism and research data at other levels of explanation, including genetics, neural structure and function, and cognition. The authors come to the conclusion that, if our goal is to explain variability and complexity, understand mechanisms and guide support decisions, 'diagnostic taxonomies that classify individuals in terms of discrete categories are ill-suited'. In this commentary, I explore alignment between their account of the transdiagnostic revolution and the neurodiversity paradigm and identify how transdiagnostic methods may promote neurodiversity-affirmative research and practice.

"A Group of Fellow Travellers Who Understand": Interviews With Autistic People About Post-diagnostic Peer Support in Adulthood

Receiving a diagnosis of autism in adulthood can be a life changing event, impacting identity, relationships, and mental health. A lack of post-diagnostic support has been highlighted by autistic adults, their allies, clinicians, and service providers. It can be a source of distress for autistic adults, reinforcing feelings of social isolation and rejection. Peer support could be a cost-effective, flexible, and sustainable model to provide community-based support for autistic adults. However, there is little research on the value of peer support, despite calls from the autistic community. This qualitative study explored autistic experiences and needs post-diagnosis, identifying specific ways that peer support may benefit them, and exploring the limitations of peer support. Twelve autistic adults who had all received an autism diagnosis in adulthood completed a semi-structured interview focussing on the diagnostic experience, post-diagnostic support needed and provided, engagement with the autistic community, and post-diagnostic peer support. Thematic analysis of interview transcripts resulted in four themes: (1) Mismatch in support needed and provided; (2) Community connection; (3) Flexible and personalised support; and (4) Sustainability. Participants indicated that peer support may be a useful mechanism to support autistic adults' post-diagnosis and offers unique opportunities not available through other support channels. Though informal peer support exists, it could be more sustainable and effective if well-supported and funded.

Personal Identity After an Autism Diagnosis: Relationships With Self-Esteem, Mental Wellbeing, and Diagnostic Timing

Adults are increasingly seeking autism diagnoses, although less is known about their experiences of diagnosis and personal identity (i.e., autism as part of "me"), and how this relates to self-esteem and wellbeing. One-hundred and fifty-one autistic adults completed an online survey including measures of self-esteem, psychological wellbeing, and autistic personal identity, which considered whether participants took pride in or were dissatisfied with being autistic. Fifty-four participants answered a qualitative question about the impact of receiving an autism diagnosis on their sense of self. Regression analyses found that greater time elapsed since diagnosis related to less dissatisfaction with autistic personal identity. We also found that more dissatisfaction with autistic personal identity predicted lower self-esteem, and more autism pride predicted higher self-esteem. Content analysis of participants' experiences supported the quantitative findings and was suggestive of an emotive post-diagnostic adjustment process. Future research should aim to identify ways to promote the development of a positive autistic personal identity post-diagnosis in adulthood.