Promoting Quality of Life: Suggestions for Mental Health Care Providers Working with Young Autistic Adults.

There is a growing population of autistic adults in need of supports from a service delivery system that, at present, fails to accommodate their needs adequately and equitably. Unfortunately, there is a shortage of trained behavioral health service providers to meet the needs of young autistic adults. Quality of life (QoL), or one's perception of, and satisfaction with, life in relation to held goals and expectations, has been identified as a key outcome of interest by autistic self-advocates. By supporting autistic clients to hone their strengths and interests, integrate various aspects of their identity, identify goals, and connect to appropriate resources, providers can promote clients' self-knowledge and self-determination, in the service of improving QoL. In this Perspectives article, we offer concrete recommendations to mental health providers, including those who do not specialize in autism, with the goal of supporting implementation of evidence-based strategies that improve QoL and promote self-determination among young autistic clients.

Why is this topic important?: Mental health care providers who are not autism specialists often feel unable to help autistic adult clients. However, relying on specialists to provide treatment for autistic adults can delay access to needed care. There is a need for well-trained clinicians and other service providers who can effectively work with autistic adults. What is the purpose of this article?: Young autistic adults face many challenges related to transition into adulthood, including greater independence desires and external expectations. The early adult years are also a period of heightened risk for emerging mental health problems. The goal of this article is to offer guidance to mental health service providers on how to effectively support autistic adults, while respecting autonomy, identity, and diversity. The guidance we offer is drawn from research, clinical practice, and lived experience. What personal or professional perspectives do the authors bring to this topic?: In addition to an autistic adult and self-advocate, the authors are clinical researchers and clinicians with expertise in working with adolescents and adults as service providers. What is already known about this topic?: Although a wider range of effective intervention practices is needed, there are a growing number of scientifically based and respectful treatments now available to address mental health concerns and promote quality of life (QoL). Unfortunately, it is widely recognized that there is a shortage of providers who work with autistic clients. One reason for the shortage is that some highly capable and well-trained providers do not treat autistic clients. What do the authors recommend?: We recommend that providers focus on strengths, abilities, and potential rather than focus on perceived deficits when working with autistic clients, so that we as a society can better meet the service needs of the autistic community. Specifically, we encourage a focus on improving QoL, structuring services to focus on self-determination and empowerment, emphasizing intersectionality or existence of multiple identities with personal meaning, and helping clients and their families navigate service systems and supports that are available. How will these recommendations help autistic adults now or in the future?: By increasing the number of providers who can work effectively work with adult autistic clients, we can hopefully minimize delays in service delivery and increase availability of high-quality services.

Overview of a Life Skills Coaching Program for Adults on the Autism Spectrum: Coaches' Perspectives.

There is considerable need to identify effective service provision models to support adults on the autism spectrum as they seek to lead independent lives. This study outlines an individualized life skills coaching program for adults with autism, "LifeMAP", and the experiences and perspectives of the coaches. Responses on a tailored questionnaire provided detailed insight into how the coaches were performing their job, the strategies they utilized, reasons for client success and difficulty, challenges faced by the coaches, and ways they were supported by program staff. Coaches' job self-efficacy and satisfaction were also examined. This study serves as a preliminary examination of individualized coaching for adults with autism from the coaches' perspective.

Prospective College Students With Autism Spectrum Disorder: Parent Perspectives.

Young adults with autism spectrum disorder (ASD) are attending university in increasing numbers. While those with ASD may be very knowledgeable within their chosen field, a range of academic-related and nonacademic challenges may hinder their success including executive functioning challenges and interpersonal issues. The purpose of this study was to conduct a preliminary investigation into the perspective of parents of high schoolers with ASD regarding their son/daughters' transition to college. Qualitative analysis of parent interviews examined the concerns and challenges they anticipated their son/daughter might experience in a university setting, as well as supports they are seeking as they consider postsecondary options. Prominent themes that emerged as areas of concern were social skills, executive functioning, academics, campus living, and support services. These findings highlight some key potential pitfalls for students with ASD which may be useful targets for prevention and remediation, as well as informing policy for colleges and universities as they consider cost-effective interventions to improve the academic success of students with ASD.

LGBTQ + and autism spectrum disorder: Experiences and challenges.

Background: Research focused on gender identity, autism spectrum disorder (ASD), and the experiences of those who identify as LGBTQ+, remains minimal. Initial findings have indicated that those on the autism spectrum may be more likely to identify as homosexual and experience more fluid gender identity. Insufficient consideration has been given to intersectionality around a disability status and gender identity, and few have focused this conversation specifically on the experiences of those with ASD. Aim: The aim of this study was to improve current understanding of the first-hand experiences of those on the autism spectrum who identify as LGBTQ+, particularly regarding challenges stemming from these dual identities. Method: A focus group was conducted with four participants with ASD who presented with a range of gender identities (as they defined them) including male, transgender; agender/nonbinary; agender; and queer. Results: Qualitative analysis of the focus group transcription identified key themes: (1) Effect of Dual Identities: experiencing dual identities, autism spectrum, and LGBTQ+; (2) Multiple Minority Stressors: challenges experienced by the participants, the impact of discrimination/misunderstanding, and holding minority statuses; (3) Isolation: barriers caused by lack of understanding; (4) Lack of Service Provision. Discussion: These preliminary findings underline the need for better support, understanding, and practices regarding sexuality and gender identity among those on the autism spectrum. The current study is important for giving voice to adults on the autism spectrum who identify as LGBTQ+, and has implications for the disability community more broadly.

Physical Activity Among Adults With Autism: Participation, Attitudes, and Barriers.

Children and adolescents with autism spectrum disorder (ASD) have shown have low levels of physical fitness, increasing risks for health-related problems associated with inactivity, such as being overweight, when compared with typically developing children. Few studies have examined physical activity (PA) among adults with ASD. This U.S.-based study examined participation in and attitudes and barriers toward PA among adults with ASD and their peers without ASD. We used standardized existing scales to survey participants for data regarding their frequency of engagement in weekly PA (strenuous, moderate, light), attitudes toward PA, expectations of others, perceived behavioral control, intention toward PA, and perceived PA barriers. Findings indicated that, on average, the ASD group compared with the comparison group reported (a) less frequent strenuous or moderate PA, (b) less positive attitudes toward PA, (c) less perceived behavioral control or ease of performing PA, and (d) more PA barriers. There was also evidence that the ASD group reported less PA intent, but there was no difference between groups regarding beliefs about others' PA expectations for them. These findings suggest a need for more PA for adults with ASD, particularly because PA has potential to attenuate such ASD challenges as anxiety, stress, and sleeping difficulties.

College Students' Knowledge and Attitudes Towards Students on the Autism Spectrum.

Young adults with autism spectrum disorder (ASD) are attending university in increasing numbers. The importance of acceptance from peers and integration into the university have been recognized as key factors for success. We examined university students' knowledge and attitudes towards students with ASD, underlying factors that contributed to such attitudes, and whether attitudes changed across two cohorts 5-years apart. The later cohort demonstrated greater knowledge and more positive attitudes toward students with ASD compared to students in the first cohort. However, knowledge was not found to be a significant predictor of attitudes and many students who were knowledgeable about ASD still reported negative attitudes toward participating in university and classroom based activities with students with ASD.

Influence of Serotonin Transporter SLC6A4 Genotype on the Effect of Psychosocial Stress on Cognitive Performance: An Exploratory Pilot Study.

BACKGROUND AND OBJECTIVE: Previous research has shown an effect of various psychosocial stressors on unconstrained cognitive flexibility, such as searching through a large set of potential solutions in the lexical-semantic network during verbal problem-solving. Functional magnetic resonance imaging has shown that the presence of the short (S) allele (lacking a 43-base pair repeat) of the promoter region of the gene (SLC6A4) encoding the serotonin transporter (5-HTT) protein is associated with a greater amygdalar response to emotional stimuli and a greater response to stressors. Therefore, we hypothesized that the presence of the S-allele is associated with greater stress-associated impairment in performance on an unconstrained cognitive flexibility task, anagrams. METHODS: In this exploratory pilot study, 28 healthy young adults were genotyped for long (L)-allele versus S-allele promoter region polymorphism of the 5-HTT gene, SLC6A4. Participants solved anagrams during the Trier Social Stress Test, which included public speaking and mental arithmetic stressors. We compared the participants' cognitive response to stress across genotypes. RESULTS: A Gene×Stress interaction effect was observed in this small sample. Comparisons revealed that participants with at least one S-allele performed worse during the Stress condition. CONCLUSIONS: Genetic susceptibility to stress conferred by SLC6A4 appeared to modulate unconstrained cognitive flexibility during psychosocial stress in this exploratory sample. If confirmed, this finding may have implications for conditions associated with increased stress response, including performance anxiety and cocaine withdrawal. Future work is needed both to confirm our findings with a larger sample and to explore the mechanisms of this proposed effect.

Supporting university students with autism spectrum disorder.

Increasing numbers of students with autism spectrum disorder are entering higher education. Their success can be jeopardized by organizational, social/emotional, and academic challenges if appropriate supports are not in place. Our objective was to evaluate the effectiveness of a support group model for university students with autism spectrum disorder in improving psychological and functional outcomes. A curriculum guided the weekly discussions and consisted of topics such as time and stress management, managing group work, and social communication. Efficacy was assessed through pre- and post self-report measures focused on self-esteem, loneliness, anxiety, and depression. Functional changes in academic and social skills were examined through qualitative analysis of focus groups. Findings from the self-report measures indicated significant reductions in feelings of loneliness and general anxiety, and a significant increase in self-esteem at the end of the program compared to the beginning. Five prominent themes were identified in the focus-group analysis and reflected how the program had positively impacted participants' skills and coping: executive functioning; goal setting; academics and resources; stress and anxiety; and social. Given the cost effectiveness of "in-house" interventions and the potential for improving academic outcomes and retention of students with autism spectrum disorder, further research examining similar program models is warranted.

Brief report: structure of personal narratives of adults with autism spectrum disorder.

Young adults with High Functioning Autism and a matched comparison group told personal narratives using a standard conversational procedure. Longest narratives were determined (i.e., number of propositions included) and scored using an analysis that looks at the organization of a narrative around a highpoint. The group with Autism Spectrum Disorder produced narratives with significantly poorer HP macrostructure and introduced proportionately fewer propositions with conjunctions. Such impairments in the ability to make sense of personal experiences both reflect and contribute to difficulty in social-emotional functioning.

Independent component analysis of the effect of L-dopa on fMRI of language processing.

L-dopa, which is a precursor for dopamine, acts to amplify strong signals, and dampen weak signals as suggested by previous studies. The effect of L-dopa has been demonstrated in language studies, suggesting restriction of the semantic network. In this study, we aimed to examine the effect of L-dopa on language processing with fMRI using Independent Component Analysis (ICA). Two types of language tasks (phonological and semantic categorization tasks) were tested under two drug conditions (placebo and L-dopa) in 16 healthy subjects. Probabilistic ICA (PICA), part of FSL, was implemented to generate Independent Components (IC) for each subject for the four conditions and the ICs were classified into task-relevant source groups by a correlation threshold criterion. Our key findings include: (i) The highly task-relevant brain regions including the Left Inferior Frontal Gyrus (LIFG), Left Fusiform Gyrus (LFUS), Left Parietal lobe (LPAR) and Superior Temporal Gyrus (STG) were activated with both L-dopa and placebo for both tasks, and (ii) as compared to placebo, L-dopa was associated with increased activity in posterior regions, including the superior temporal area (BA 22), and decreased activity in the thalamus (pulvinar) and inferior frontal gyrus (BA 11/47) for both tasks. These results raise the possibility that L-dopa may exert an indirect effect on posterior regions mediated by the thalamus (pulvinar).

Lack of noradrenergic modulation of indirect semantic priming.

Norepinephrine and dopamine are both believed to affect signal-to-noise in the cerebral cortex. Dopaminergic agents appear to modulate semantic networks during indirect semantic priming, but do not appear to affect problem solving dependent on access to semantic networks. Noradrenergic agents, though, do affect semantic network dependent problem solving. We wished to examine whether noradrenergic agents affect indirect semantic priming. Subjects attended three sessions: one each after propranolol (40 mg) (noradrenergic antagonist), ephedrine (25 mg) (noradrenergic agonist), and placebo. During each session, closely related, distantly related, and unrelated pairs were presented. Reaction times for a lexical decision task on the target words (second word in the pair) were recorded. No decrease in indirect semantic priming occurred with ephedrine. Furthermore, across all three drugs, a main effect of semantic relatedness was found, but no main effect of drug, and no drug/semantic relatedness interaction effect. These findings suggest that noradrenergic agents, with these drugs and at these doses, do not affect indirect semantic priming with the potency of dopaminergic drugs at the doses previously studied. In the context of this previous work, this suggests that more automatic processes such as priming and more controlled searches of the lexical and semantic networks such as problem solving may be mediated, at least in part, by distinct mechanisms with differing effects of pharmacological modulation.

Effect of propranolol on verbal problem solving in autism spectrum disorder.

The noradrenergic system modulates performance on tasks dependent on semantic and associative network flexibility (NF) in individuals without neurodevelopmental diagnoses in experiments using a beta-adrenergic antagonist, propranolol. Some studies suggest drugs decreasing noradrenergic activity are beneficial in ASD. In individuals without neurodevelopmental diagnoses, propranolol is beneficial only for difficult NF-dependent problems. However, in populations with altered noradrenergic regulation, propranolol also benefits performance for simple problems. Due to decreased flexibility of access to networks in ASD, we wished to examine the effect of propranolol on NF in ASD. ASD subjects benefited from propranolol on simple anagrams, whereas control subjects were impaired by propranolol. Further study will be necessary to confirm this finding in a larger sample and to compare clinical response with cognitive response to propranolol.

Functional connectivity in an fMRI study of semantic and phonological processes and the effect of L-Dopa.

We describe an fMRI experiment examining the functional connectivity (FC) between regions of the brain associated with semantic and phonological processing. We wished to explore whether L-Dopa administration affects the interaction between language network components in semantic and phonological categorization tasks, as revealed by FC. We hypothesized that L-Dopa would decrease FC due to restriction of the semantic network. During two test sessions (placebo and L-Dopa) each participant performed two fMRI runs, involving phonological and semantic processing. A number of brain regions commonly activated by the two tasks were chosen as regions if interest: left inferior frontal, left posterior temporal and left fusiform gyri, and left parietal cortex. FC was calculated and further analyzed for effects of either the drug or task. No main effect for drug was found. A significant main effect for task was found, with a greater average correlation for the phonological task than for the semantic task. These findings suggest that language areas are activated in a more synchronous manner for phonological than for semantic tasks. This may relate to the fact that phonological processes are mediated to a greater extent within language areas, whereas semantic tasks likely require greater interaction outside of the language areas. Alternatively, this may be due to differences in the attentional requirements of the two tasks.

Increased task difficulty results in greater impact of noradrenergic modulation of cognitive flexibility.

Previous research suggests that the noradrenergic system modulates certain types of cognitive flexibility. This study compared various doses of beta-adrenergic antagonists for their effect on cognitive flexibility in problem solving, and how task difficulty interacts with this effect, as well as the effect of beta-adrenergic antagonists on other tasks. Anagram task performance was compared in 72 subjects using a within-subject design for propranolol at 20 mg, 40 mg, 60 mg, and placebo in a double-blinded manner, and the effects of subject ability and task difficulty were examined. We also examined the effect of the 40 mg propranolol dose on a range of other tasks. Overall, more anagram problems were solved while on propranolol 40 mg than on placebo. Subjects least able to solve the problems benefited significantly from 40 mg of propranolol. Also, for all subjects the most difficult problems were solved more quickly with propranolol 40 mg than placebo. Benefits were also seen for word fluency and backward digit span. Therefore, noradrenergic modulation of cognitive flexibility is affected by how much difficulty the subject is encountering when searching for the solution, a pattern consistent with what might be expected in an effect on the search of the semantic and associative network.

Effect of the cold pressor test on memory and cognitive flexibility.

Cognitive flexibility is affected by stress. The cold pressor test is a known adrenergic stressor that impairs memory, but the effect on cognitive flexibility is unknown. Sixteen subjects were given cognitive flexibility and memory tasks with and without one hand immersed in cold water. Memory was impaired in the cold pressor condition but there was no effect on cognitive flexibility. The lack of a cold pressor effect on cognitive flexibility may result from an isolated effect on the peripheral noradrenergic system, whereas indirect effects due to nociception on memory may occur.

Effect of propranolol on naming in chronic Broca's aphasia with anomia.

Previous research suggests that the noradrenergic system modulates flexibility of access to the lexical-semantic network, with propranolol benefiting normal subjects in lexical-semantic problem solving tasks. Patients with Broca's aphasia with anomia have impaired ability to access appropriate verbal output for a given visual stimulus in a naming task. Therefore, we tested naming in a pilot study of chronic Broca's aphasia patients with anomia after propranolol and after placebo in a double-blinded crossover manner. Naming was better after propranolol than after placebo, suggesting a potential benefit from propranolol in chronic Broca's aphasia with anomia. Larger follow-up studies are necessary to further investigate this effect.

Decreased false memory for visually presented shapes and symbols among adults on the autism spectrum.

Individuals with autism spectrum disorders (ASD) have been shown in some studies to be less susceptible to the verbal "false memory" effect, perhaps due to restricted semantic associative networks. High-functioning individuals with ASD can demonstrate subtle language impairments. However, relative preservation of spatial skills can also be observed. This study investigated false memory in both visual and verbal paradigms to elucidate whether adults with ASD would be more or less prone to illusory recognition in a visual paradigm that contained slides of geometric figures with minimal linguistic and semantic associative representation. In the verbal paradigm, modeled on the Deese-Roediger-McDermott method, those with ASD did not perform significantly better than a matched comparison group. In contrast, in the visual paradigm those with ASD were significantly better able to discriminate true items from lure items and were less likely to falsely recognize the lures. Findings from the visual paradigm provide further evidence of restricted associative networks in ASD, particularly in the spatial domain.

Beta-adrenergic modulation of cognitive flexibility during stress.

Stress-induced activation of the locus ceruleus-norepinephrine (LC-NE) system produces significant cognitive and behavioral effects, including enhanced arousal and attention. Improvements in discrimination task performance and memory have been attributed to this stress response. In contrast, for other cognitive functions that require cognitive flexibility, increased activity of the LC-NE system may produce deleterious effects. The aim of the present study was to determine the effect of pharmacological modulation of the LC-NE system on stress-induced impairments in cognitive flexibility performance in healthy individuals. Cognitive performance, plus psychological and physiological parameters for 16 adults without any history of anxiety disorders, was assessed during four test sessions: stress and no-stress, with each condition tested after administration of propranolol and placebo. The Trier Social Stress Test, a public-speaking and mental arithmetic stressor, was presented to participants for the stress sessions, whereas a similar, but nonstressful, control task (reading, counting) was utilized for the no-stress sessions. Tests of cognitive flexibility included lexical-semantic and associative problem-solving tasks (anagrams, Compound Remote Associates Test). Visuo-spatial memory and motor processing speed tests served as control tasks. Results indicate that (1) stress impaired performance on cognitive flexibility tasks, but not control tasks; (2) compared to placebo, cognitive flexibility improved during stress with propranolol. Therefore, psychological stress, such as public speaking, negatively impacts performance on tasks requiring cognitive flexibility in normal individuals, and this effect is reversed by beta-adrenergic antagonism. This may provide support for the hypothesis that stress-related impairments in cognitive flexibility are related to the noradrenergic system.

Problem solving ability in patients with mild cognitive impairment.

BACKGROUND AND OBJECTIVE: It is important to determine which patients with mild cognitive impairment (MCI) are at risk for progression to dementia. The presence of mild impairments not restricted to the domain of memory may suggest such progression. Our goal is to determine how well a visuospatial problem solving task assessing the cumulative burden of frontal and posterior damage differentiates MCI patients from matched controls. METHODS: Twenty-six patients with MCI [Clinical Dementia Rating (CDR) score of 0.5] and mini-mental state examination (MMSE) scores of at least 24/30, were compared with 20 age and education level matched controls without cognitive impairment. All patients were given the MMSE, Hopkins Verbal Learning Test (HVLT), Boston Naming Test (BNT), Rey Complex Figures copying (RCF), anagrams, and visuospatial problem solving battery (VPS). The VPS is a complex problem solving task, which we predicted would better discriminate patient groups than the relatively simpler tasks. RESULTS: Differences existed between groups on most tasks, but logistic regression revealed that the VPS discriminated the 2 groups better than the other nonmemory cognitive tests. CONCLUSIONS: The VPS, a problem solving task assessing the cumulative burden of frontal and posterior damage is more sensitive for detecting nonmemory impairments in MCI than other tasks. Future research will be needed to determine if impairment in the VPS is a sensitive predictor of progression to dementia or treatment response.

Network model of decreased context utilization in autism spectrum disorder.

Individuals with autism spectrum disorders (ASD) demonstrate impaired utilization of context, which allows for superior performance on the "false memory" task. We report the application of a simplified parallel distributed processing model of context utilization to the false memory task. For individuals without ASD, experiments support a model wherein presentation of one word, e.g., ''apple,'' strongly activates the neighboring nodes of closely related words such as ''fruit,'' ''tree,'' whereas in ASD these neighboring nodes are relatively less activated. We demonstrate this model to be consistent with the superior performance on recognition testing on the false memory test, but not on free recall. This may have an anatomic basis in diminished hippocampal neuronal arborization and the abnormal minicolumnar pathology in ASD.