Stakeholder informed development of the Emotion Awareness and Skills Enhancement team-based program (EASE-Teams)

Study protocol for a randomized controlled trial of Regulating Together (RT), a group therapy for emotion dysregulation in school-age autistic youth and their caregivers

BACKGROUND

Emotion dysregulation is a common concern in autistic youth. Growing evidence suggests emotion dysregulation underlies multiple co-occurring issues in autism, including externalizing (e.g., aggression, irritability) and internalizing (e.g., anxiety, depression) disorders, and thus may serve as a key transdiagnostic treatment target. Emotion dysregulation during middle childhood (8-12 years) is concurrently and longitudinally associated with social difficulties and poorer quality of life for autistic individuals, highlighting a key window for intervention. There is an urgent need for treatments for emotion dysregulation in school-age autistic youth that involve caregivers to maximize skill generalization. To address this need, our group developed Regulating Together, an intensive outpatient group program targeting emotion dysregulation in 8- to 12-year-old autistic youth that integrates strategies from cognitive behavioral therapy, mindfulness and acceptance-based therapies, and parent training programs. Building on our previous non-randomized trials of Regulating Together, we document the study protocol for our first, and ongoing, randomized controlled trial comparing Regulating Together to an active control condition.

METHODS

This is a five-year randomized controlled trial comparing Regulating Together to Achieving Independence and Mastery in School (AIMS), an active control condition targeting executive functioning difficulties, in an outpatient hospital setting. Enrollment is ongoing and the study is expected to be completed in late Fall of 2026. Participants will be 144 autistic youth (8-12 years; IQ ≥ 65) randomized to either 5-week treatment condition. A comprehensive assessment battery integrating self-, caregiver-, and clinician-report information, functional outcomes (i.e., number of psychiatric hospitalizations), objective outcomes (probabilistic reversal learning task), and biobehavioral measures (heart rate variability) will be collected and compared between baseline (Week 0), post-treatment (Week 7), post-generalization (Week 16), and at long-term follow-up (Week 29).

DISCUSSION

This is the first comparison of the Regulating Together program to an active treatment condition. Findings from this study will build on previous piloted iterations of Regulating Together by characterizing its efficacy in relation to active treatment, testing moderators of treatment response, and identifying barriers and facilitators to treatment access, impact, and sustainability. Following completion of this study, we will pursue implementation studies (e.g., testing program implementation and effectiveness in community settings). Dissemination and external provider training efforts are ongoing.

TRIAL REGISTRATION

Trial registration took place through ClinicalTrials.gov (NCT05803369) on March 14th, 2023.

Toward improved understanding and treatment of self-injurious behaviors in autistic individuals with profound intellectual disability

Self-injurious behaviors (SIB) commonly occur in autism spectrum disorder (ASD) and span diverse topographies of self-inflicted behaviors ranging from head banging to hitting oneself against hard objects. Despite the high rates of SIB in autistic individuals, relatively little research has focused on psychological factors associated with the development and maintenance of SIB in individuals with autism and moderate-profound intellectual disability (ID). This commentary synthesizes existing literature on SIB and highlights the need for more research focused on psychological correlates and mechanisms in autistic individuals with moderate-profound ID. We highlight the key role of difficulties in emotion regulation (ER) and co-occurring internalizing symptoms in the manifestation of self-harm behaviors in clinical samples and autism. Furthermore, this commentary proposes a framework for understanding the interplay between poor ER and internalizing symptoms in the development and maintenance of SIB in autistic individuals with moderate-profound ID. Specifically, we explore the emergence of SIB in the context of precipitating cues that trigger strong emotions, ER processes and strategy deployment, and co-occurring internalizing symptoms. Future directions and implications for longitudinal research, measurement development, and clinical treatments are discussed.

Helping Practitioners Stop, Drop, and Roll: Suggestions to Help Improve Responses to Intense Clinical Events

Community practitioners inconsistently implement evidence-based interventions. Implementation science emphasizes the importance of some practitioner characteristics, such as motivation, but factors such as practitioners' emotion regulation and cognitive processing receive less attention. Practitioners often operate in stressful environments that differ from those in which they received training. They may underestimate the impact of their emotional state on their ability to deliver evidence-based interventions. This "hot-cold state empathy gap" is not well studied in mental health care. In this Open Forum, the authors describe scenarios where this gap is affecting practitioners' ability to implement evidence-based practices. The authors provide suggestions to help practitioners plan for stressful situations.

Emotion regulation and emotion dysregulation in children and adolescents with Autism Spectrum Disorder: A meta-analysis of evaluation and intervention studies

Children and adolescents with Autism Spectrum Disorder (ASD) often experience challenges in emotion regulation (ER) and emotion dysregulation (ED) which can interfere with their adaptive functioning. This study aimed to systematically review and meta-analyze the evidence on ER/ED in children and/or adolescents with ASD, examining its relationship with the following variables: internalizing and externalizing symptoms, cognitive function and social skills, and the effectiveness of non-pharmacological interventions addressing ER difficulties. Both electronic and manual searches were conducted to identify potential studies. Fifty-five studies were included in the meta-analysis. A statistically significant between-group difference was found, suggesting greater ER/ED challenges in the ASD group. Also, the ASD group showed more maladaptive ER strategies and fewer adaptive ER strategies compared to the non-ASD participants. Additionally, more severe ASD and poorer social skills were associated with greater ED and poorer ER skills, respectivelly. Furthermore, there was a significant correlation between internalizing symptomatology and both adaptive and maladaptive ER strategies. Studies of non-pharmacological interventions showed significant improvement in both ER and ED. These results imply that assessing ER/ED in children and adolescents with ASD should be part of the evaluation process, and it should also be a focal point for intervention in this population.

Effects of nonsocial and circumscribed interest images on neural mechanisms of emotion regulation in autistic adults

Introduction

Emotion dysregulation is commonly reported among autistic individuals. Prior work investigating the neurofunctional mechanisms of emotion regulation (ER) in autistic adults has illustrated alterations in dorsolateral prefrontal cortex (dlPFC) activity, as well as concurrent atypical patterns of activation in subcortical regions related to affect during cognitive reappraisal of social images. Whereas most research examining ER in autism has focused on regulation of negative emotions, the effects of regulating positive emotions has been generally understudied. This is surprising given the relevance of positive motivational states to understanding circumscribed interests (CI) in autism.

Methods

Accordingly, the purpose of this study was to use fMRI with simultaneous eye-tracking and pupillometry to investigate the neural mechanisms of ER during passive viewing and cognitive reappraisal of a standardized set of nonsocial images and personalized (self-selected) CI images.

Results

The autistic group demonstrated comparatively reduced modulation of posterior cingulate cortex (PCC) activation during cognitive reappraisal of CI images compared to viewing of CI, although no eye-tracking/pupillometry differences emerged between-groups. Further, the autistic group demonstrated increased PCC connectivity with left lateral occipital and right supramarginal areas when engaging in cognitive reappraisal vs. viewing CI.

Discussion

In autistic adults, CI may be differentially modulated via PCC. Considering the documented role of the PCC as a core hub of the default mode network, we further postulate that ER of CI could potentially be related to self-referential cognition.