Recovery of adults with autism spectrum disorder during intensive inpatient treatment: a qualitative study.

Introduction: Although some adults with autism spectrum disorder (ASD) require intensive and specialized ASD treatment, there is little research on how these adults experience the recovery process. Recovery is defined as the significant improvement in general functioning compared to the situation prior to treatment. Methods: This qualitative study describes the recovery process from the perspective of adults on the autism spectrum during intensive inpatient treatment. Semi-structured interviews (n = 15) were carried out and analyzed according to the principles of grounded theory. Results: Our results indicate that, given the specific characteristics of autism, therapeutic interventions and goal-oriented work cannot be carried out successfully, and the recovery process cannot begin, if no good working relationship has been established, and if care is not organized in ways that a person on the autism spectrum finds clear and predictable.

The effectiveness and safety of dialectical behavior therapy for suicidal ideation and behavior in autistic adults: a pragmatic randomized controlled trial.

BACKGROUNDS: Many autistic people in mental health are suicidal. This study evaluated the effectiveness of dialectical behavior therapy (DBT) v. treatment as usual (TAU) in reducing suicidal ideation and suicide attempts. METHODS: At six Dutch mental health centers, 123 outpatients (18-65 years) with DSM-5 diagnosed autism spectrum disorder (ASD) and suicidal behavior were randomly assigned to the DBT intervention group (n = 63) or TAU control group (n = 60). Assessments were conducted at baseline, post-treatment at 6 months and 12-month follow-up. The primary outcomes were severity of suicidal ideation and frequency of suicide attempts. The severity of depression and social anxiety were secondary outcomes. RESULTS: At end-of-treatment, DBT significantly reduced both suicidal ideation (z = -2.24; p = 0.025; b = -4.41; s.e. = 197.0) and suicide attempts (z = -3.15; p = 0.002; IRR = 0.046; s.e. = 0.045) compared to TAU, but lost statistical significance at the 12-month follow-up. Depression severity significantly decreased with DBT (z = -1.99; p = 0.046: b = -2.74; s.e. = 1.37) remaining so at 12 months (z = -2.46; p = 0.014; b = -3.37; s.e. = 1.37). No effects were observed on social anxiety. Severe adverse events included two suicides in the TAU condition. CONCLUSIONS: DBT is an acceptable, safe, and short-term effective intervention to reduce suicidal ideation and suicide attempts in autistic adults with suicidal behavior.

Sensory processing and alcohol use in adults with autism spectrum disorder.

The association between substance use and autism spectrum disorder (ASD) is complex. Although sensory processing difficulties are highly prevalent in individuals with ASD, data on the association between sensory processing and substance use in ASD are limited. This study aimed to investigate the association between sensory processing patterns and alcohol use in adults with ASD. Kruskal-Wallis tests were performed on questionnaire data (Adolescent/Adult Sensory Profile and Alcohol Use Disorders Identification Test - Consumption) of 101 adults with ASD. Sensory processing difficulties are associated with alcohol use in adults with ASD. Differences in sensory processing between alcohol-based subgroups vary per specific sensory processing pattern: drinkers reported 6.5 to 8 points higher levels of low registration [χ2(2) = 12.408, p = .002, 99 % CI (.002.002)], non-hazardous drinkers reported 9 points higher levels of sensory sensitivity [χ2(2) = 6.868, p = .031, 99 % CI (.031, .032)], and hazardous drinkers reported 7.5 points higher levels of sensory seeking [χ2(2) = 6.698, p = .034, 99 % CI (.034, .035)], all in comparison with non-drinkers on scales ranging from 15 to 75. Our proof-of-concept study indicates that vulnerability in some individuals with ASD for substance use disorders might be explained by sensory processing difficulties. Whether alcohol is used as 'self-medication' or is associated with other neurobiological vulnerabilities needs further investigation in larger follow-up studies.

Grievance-fueled violence can be better understood using an enactive approach.

Understanding lone actor grievance-fueled violence remains a challenge. We believe that the concept of grievance provides an opportunity to add an engaged, first-person perspective to the assessment of lone actor extreme violence. We propose an enactivist philosophical approach that can help to understand the why and how of the pathway from grievance to violent extremism. Enactivism sees grievance as a dynamic, interpersonal, and context-sensitive construct that indicates how (potential) offenders make sense of the world they live in and how under certain circumstances it fuels violent behavior. Hence, grievance should not be understood as a given thing, but as an unfolding experience that involves sense-making through (regulation of one's) interaction with the (social) environment. This (self-)relational and ecological understanding requires another approach than looking at demographic factors or life histories, only from an outsider's perspective. Enactivism invites us to look at such risk factors as external indices of an ongoing process of active self-regulation and sense-making, and in some cases spiraling toward extreme violence. To understand the mindset of the offender we need to look more in depth at the processes that shape this mindset: why does this person, with this history, in this context, and at this point in time, proceed to use violence? The enactivist approach to the mind offers a complementary framework that may help us to understand the dynamics of grievance as a possible precursor to violent extremism. It also helps to appreciate why the relative unpredictability of the pathway toward lone actor extreme violence is not necessarily a sign of empirical weakness but a matter of principle due to the non-linearity of the processes involved. We end by summarizing how enactivism could contribute to the prevention of extremist violence and research and how it can help to avoid reinforcing stigmas and re-establishing a confirmation bias.

Sensory processing difficulties in psychiatric disorders: A meta-analysis.

In clinical practice, many individuals with psychiatric disorders report difficulties in sensory processing, including increased awareness or sensitivity to external stimuli. In this meta-analysis, we examined the sensory processing patterns of adolescent and adult individuals with a broad spectrum of different psychiatric conditions. A systematic search in various databases resulted in the inclusion of 33 studies (N=2008), all using the Adolescent/Adult Sensory Profile (AASP). By comparing diagnostic subgroups to the corresponding reference group of the AASP, we detected a general pattern of sensory processing, indicating elevated levels of low registration, sensory sensitivity and sensory avoiding and lowered sensory seeking behavior in patients with different types of psychiatric disorders. The majority of effect sizes were large to very large. In conclusion, sensory processing difficulties can be considered as a non-specific transdiagnostic phenotype associated with a broad spectrum of psychiatric conditions. Further research into the relevance and role of sensory processing difficulties in psychiatric disorders may improve long-term prognosis and treatment.

Sensory Processing, Perceived Stress and Burnout Symptoms in a Working Population during the COVID-19 Crisis.

Although previous research suggests an association between sensory processing and perceived stress in a broad spectrum of mental health conditions, it remains unclear whether this phenomenon occurs independently from psychopathology. The present study investigated the association between sensory processing patterns, perceived stress and occupational burnout as a stress-related condition in a working population. We focused on different aspects of sensory processing and used the momentum of a particularly stressful period: during the first months of the global COVID-19 crisis. A total of 116 workers at a mental healthcare institution in The Netherlands completed the Adolescent/Adult Sensory Profile (AASP), the Perceived Stress Scale (PSS-10) and the Burnout Assessment Tool (BAT). Our results demonstrated that higher scores on sensory sensitivity and low registration were associated with higher scores on perceived stress and core burnout symptoms. Sensory hypersensitivity was also associated with more secondary burnout symptoms. Associations were not driven by underlying sensory-related disorders (e.g., ASD or ADHD). In conclusion, sensory processing difficulties are relevant predictors of stress and occupational burnout, also in healthy employees. This phenomenon warrants further attention, as relatively simple adjustments in working environment may possess important preventive effects.

Sensory Processing and Aggressive Behavior in Adults with Autism Spectrum Disorder.

Autism spectrum disorder (ASD) may be accompanied by aggressive behavior and is associated with sensory processing difficulties. The present study aims to investigate the direct association between sensory processing and aggressive behavior in adults with ASD. A total of 101 Dutch adult participants with ASD, treated in outpatient or inpatient facilities, completed the Adult/Adolescent Sensory Profile (AASP), the Reactive-Proactive Aggression Questionnaire (RPQ), and the Aggression Questionnaire-Short Form (AQ-SF). Results revealed that sensory processing difficulties are associated with more aggressive behavior (f2=0.25), more proactive (f2=0.19) and reactive aggression (f2=0.27), more physical (f2=0.08) and verbal aggression (f2=0.13), and more anger (f2=0.20) and hostility (f2=0.12). Evidence was found for an interaction of the neurological threshold and behavioral response on total aggression and hostility. Participants with higher scores in comparison to the norm group in sensory sensitivity had the highest risk of aggressive behavior. In conclusion, clinical practice may benefit from applying detailed diagnostics on sensory processing difficulties when treating aggressive behavior in adults with ASD.

The effect of dialectical behaviour therapy in autism spectrum patients with suicidality and/ or self-destructive behaviour (DIASS): study protocol for a multicentre randomised controlled trial.

BACKGROUND: Many persons with autism spectrum disorder (ASD) are treated in long-term specialised care. In this population, suicidal behaviour troubles patients, families, and specialists in the field because it is difficult to treat. At present, there is no documented effective therapy for suicidal behaviour in ASD (Autism Research 7:507-521, 2014; Crisis 35:301-309, 2014). Dialectical Behaviour Therapy (DBT) is an efficacious treatment programme for chronically suicidal and/or self-harm behaviour in patients with Borderline Personality Disorder (J Psychiatry 166:1365-1374, 2014; Linehan MM. Cognitive behavioural therapy of borderline personality disorder. 1993). This study will evaluate the efficacy of DBT in persons with ASD and suicidal/ self- destructive behaviour in a multicentre randomised controlled clinical trial. METHOD: One hundred twenty-eight persons with autism and suicidal and/or self-harming behaviour will be recruited from specialised mental healthcare services and randomised into two conditions: 1) the DBT condition in which the participants have weekly individual cognitive behavioural therapy sessions and a 2.5 h skills training group session twice per week during 6 months, and 2) the treatment as usual condition which consists of weekly individual therapy sessions of 30-45 min with a psychotherapist or social worker. Assessments will take place at baseline, at post-treatment (6 months), and after a follow-up period of 12 months. The mediators will also be assessed at 3 months. The primary outcome is the level of suicidal ideation and behaviour. The secondary outcomes are anxiety and social performance, depression, core symptoms of ASD, quality of life, and cost-utility. Emotion regulation and therapeutic alliance are hypothesised to mediate the effects on the primary outcome. DISCUSSION: The results from this study will provide an evaluation of the efficacy of DBT treatment in persons with ASD on suicidal and self-harming behaviour. The study is conducted in routine mental health services which enhances the generalisability of the study results to clinical practice. TRIAL REGISTRATION: ISRCTN96632579. Registered 1 May 2019. Retrospectively registered.

Self-reported Suicidality in Male and Female Adults with Autism Spectrum Disorders: Rumination and Self-esteem.

Rumination and low self-esteem are associated with suicidality, and with autism spectrum disorders (ASD). However, rumination and self-esteem in relation to suicidality in adults with ASD have not been examined. This cross-sectional study (n = 75; 46 males and 29 females) investigates the relation of rumination and self-esteem to the absence/presence of suicidal ideation (SUIC+/-), history of attempted suicide (HAS), and severity of suicidality. Multivariate analysis of variance showed that self-esteem was significantly associated with SUIC+/-, whereas rumination was significantly associated with HAS. Multiple regression analysis showed that rumination and self-esteem were independently associated with severity of suicidality, but these lose their significant contribution, when statistically controlling for depression. The prevalence of suicidal ideation was 66.6%; gender was not a significant factor.

Temperament and character as risk factor for suicide ideation and attempts in adults with autism spectrum disorders.

Persons with autism spectrum disorders (ASDs) are suggested to have an increased risk for suicide ideation and suicide attempts, but this topic is largely understudied. Research indicates that temperament and character traits are associated with suicidal behavior in persons without ASD, with higher scores for novelty seeking (NS), harm avoidance (HA), and self-transcedence (ST), and lower scores for self-directedness (SD) and cooperativeness (CO). Usually persons with ASD have temperament and character profiles with high HA, and low NS, reward dependence (RD), SD, and CO. The aim is to investigate whether there is a relationship between temperament and character traits and suicide ideation and attempts in adults with ASD. Seventy-four adults with ASD participated by completing self-report measures on suicide thoughts and behavior, depression, and temperament. Independent sample t-tests were conducted to compare scores between attempters versus nonattempters and between ideators versus nonideators. Regression analysis was performed to explore the predictive value of temperament and character. T-tests showed lower NS and SD, and higher HA for ideators versus nonideators, but not for attempters versus nonattempters. Regression models showed no significant relation between suicide ideation and NS, SD, HA after the latter were controlled for the significant influence of depression. Temperament and character can probably not be used for predicting suicide ideation and attempts, based on results from the current sample. Clinicians must take note of the high prevalence and risk of depression among persons with ASD, which may be under-reported. Autism Res 2020, 13: 104-111. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: The aim of the current study was to uncover risk factors for suicide ideation and attempts in adults with autism, since this urgent topic is largely understudied. We initially investigated whether temperament and character could be risk factors, but found no association. However, we did find that depression might be a high predictor for suicide ideation, which could remain under-reported in adults with autism, due to impaired communication and problems with expressing emotions and thoughts.

Mindfulness-based cognitive therapy v. treatment as usual in adults with ADHD: a multicentre, single-blind, randomised controlled trial.

BACKGROUND: There is a high need for evidence-based psychosocial treatments for adult attention-deficit hyperactivity disorder (ADHD) to offer alongside treatment as usual (TAU). Mindfulness-based cognitive therapy (MBCT) is a promising psychosocial treatment. This trial investigated the efficacy of MBCT + TAU v. TAU in reducing core symptoms in adults with ADHD. METHODS: A multicentre, single-blind, randomised controlled trial (ClinicalTrials.gov: NCT02463396). Participants were randomly assigned to MBCT + TAU (n = 60), an 8-weekly group therapy including meditation exercises, psychoeducation and group discussions, or TAU only (n = 60), which reflected usual treatment in the Netherlands and included pharmacotherapy and/or psychoeducation. Primary outcome was ADHD symptoms rated by blinded clinicians. Secondary outcomes included self-reported ADHD symptoms, executive functioning, mindfulness skills, self-compassion, positive mental health and general functioning. Outcomes were assessed at baseline, post-treatment, 3- and 6-month follow-up. Post-treatment effects at group and individual level, and follow-up effects were examined. RESULTS: In MBCT + TAU patients, a significant reduction of clinician-rated ADHD symptoms was found at post-treatment [M difference = -3.44 (-5.75, -1.11), p = 0.004, d = 0.41]. This effect was maintained until 6-month follow-up. More MBCT + TAU (27%) than TAU participants (4%) showed a ⩾30% reduction of ADHD symptoms (p = 0.001). MBCT + TAU patients compared with TAU patients also reported significant improvements in ADHD symptoms, mindfulness skills, self-compassion and positive mental health at post-treatment, which were maintained until 6-month follow-up. Although patients in MBCT + TAU compared with TAU reported no improvement in executive functioning at post-treatment, they did report improvement at 6-month follow-up. CONCLUSIONS: MBCT might be a valuable treatment option alongside TAU for adult ADHD aimed at alleviating symptoms.

Eye Movement Desensitization and Reprocessing (EMDR) Therapy as a Feasible and Potential Effective Treatment for Adults with Autism Spectrum Disorder (ASD) and a History of Adverse Events.

The study investigated whether EMDR is a feasible therapy for adults with ASD and a history of adverse events, and whether it is associated with reductions in symptoms of PTSD, psychological distress and autism. Participants received 6 to 8 weeks treatment as usual (TAU), followed by a maximum of 8 sessions EMDR added to TAU, and a follow-up of 6-8 weeks with TAU only. Results showed a significant reduction of symptoms of post-traumatic stress (IES-R: d = 1.16), psychological distress (BSI: d = 0.93) and autistic features (SRS-A: d = 0.39). Positive results were maintained at follow-up. The results suggest EMDR therapy to be a feasible and potentially effective treatment for individuals with ASD who suffer from the consequences of exposure to distressing events.

Cognitive behavioural therapy and mindfulness based stress reduction may be equally effective in reducing anxiety and depression in adults with autism spectrum disorders.

Anxiety and depression co-occur in 50-70% of adults with autism spectrum disorder (ASD) but treatment methods for these comorbid problems have not been systematically studied. Recently, two ASD-tailored protocols were published: mindfulness based stress reduction (MBSR) and cognitive behavioural therapy (CBT). We wanted to investigate if both methods are equally effective in reducing anxiety and depression symptoms among adults with ASD. 59 adults with ASD and anxiety or depression scores above 7 on the Hospital Anxiety and Depression Scale, gave informed consent to participate; 27 followed the CBT protocol, and 32 the MBSR treatment protocol. Anxiety and depression scores, autism symptoms, rumination, and global mood were registered at the start, at the end of the 13-week treatment period, and at 3-months follow-up. Irrational beliefs and mindful attention awareness were used as process measures during treatment and at follow-up. Results indicate that both MBSR and CBT are associated with a reduction in anxiety and depressive symptoms among adults with ASD, with a sustained effect at follow-up, but without a main effect for treatment group. A similar pattern was seen for the reduction of autistic symptoms, rumination and the improvement in global mood. There are some indications that MBSR may be preferred over CBT with respect to the treatment effect on anxiety when the scores on measures of irrational beliefs or positive global mood at baseline are high. Mindfulness and cognitive behavioral therapies are both promising treatment methods for reducing comorbid anxiety and depression in adults with ASD.

Mindfulness based cognitive therapy versus treatment as usual in adults with attention deficit hyperactivity disorder (ADHD).

BACKGROUND: Adults with attention deficit hyperactivity disorder (ADHD) often present with a lifelong pattern of core symptoms that is associated with impairments of functioning in daily life. This has a substantial personal and economic impact. In clinical practice there is a high need for additional or alternative interventions for existing treatments, usually consisting of pharmacotherapy and/or psycho-education. Although previous studies show preliminary evidence for the effectiveness of mindfulness-based interventions in reducing ADHD symptoms and improving executive functioning, these studies have methodological limitations. This study will take account of these limitations and will examine the effectiveness of Mindfulness Based Cognitive Therapy (MBCT) in further detail. METHODS/DESIGN: A multi-centre, parallel-group, randomised controlled trial will be conducted in N = 120 adults with ADHD. Patients will be randomised to MBCT in addition to treatment as usual (TAU) or TAU alone. Assessments will take place at baseline and at three, six and nine months after baseline. Primary outcome measure will be severity of ADHD symptoms rated by a blinded clinician. Secondary outcome measures will be self-reported ADHD symptoms, executive functioning, mindfulness skills, self-compassion, positive mental health and general functioning. In addition, a cost-effectiveness analysis will be conducted. DISCUSSION: This trial will offer valuable information about the clinical and cost-effectiveness of MBCT in addition to TAU compared to TAU alone in adults swith ADHD. TRIAL REGISTRATION: ClinicalTrials.gov NCT02463396. Registered 8 June 2015.

Predictive validity of self-report questionnaires in the assessment of autism spectrum disorders in adults.

While various screening instruments for autism spectrum disorders are widely used in diagnostic assessments, their psychometric properties have not been simultaneously evaluated in the outpatient setting where these instruments are used most. In this study, we tested the Ritvo Autism Asperger Diagnostic Scale-Revised and two short versions of the Autism-Spectrum Quotient, the AQ-28 and AQ-10, in 210 patients referred for autism spectrum disorder assessment and in 63 controls. Of the 210 patients, 139 received an autism spectrum disorder diagnosis and 71 received another psychiatric diagnosis. The positive predictive values indicate that these tests correctly identified autism spectrum disorder patients in almost 80% of the referred cases. However, the negative predictive values suggest that only half of the referred patients without autism spectrum disorder were correctly identified. The sensitivity and specificity of each of these instruments were much lower than the values reported in the literature. In this study, the sensitivity of the Ritvo Autism Asperger Diagnostic Scale-Revised was the highest (73%), and the Autism-Spectrum Quotient short forms had the highest specificity (70% and 72%). Based on the similar area under the curve values, there is no clear preference for any of the three instruments. None of these instruments have sufficient validity to reliably predict a diagnosis of autism spectrum disorder in outpatient settings.

Temperament and character as endophenotype in adults with autism spectrum disorders or attention deficit/hyperactivity disorder.

Autism spectrum disorder and attention deficit/hyperactivity disorder overlap in several ways, raising questions about the nature of this comorbidity. Rommelse et al. published an innovative review of candidate endophenotypes for autism spectrum disorder and attention deficit/hyperactivity disorder in cognitive and brain domains. They found that all the endophenotypic impairments that were reviewed in attention deficit/hyperactivity disorder were also present in autism spectrum disorder, suggesting a continuity model with attention deficit/hyperactivity disorder as "a light form of autism spectrum disorder." Using existing data, 75 adults with autism spectrum disorder and 53 with attention deficit/hyperactivity disorder were directly compared on autistic symptoms with the autism spectrum quotient, and on the endophenotypic measure of temperament and character, using the Abbreviated (Dutch: Verkorte) Temperament and Character Inventory. Based on the hypothesis that attention deficit/hyperactivity disorder and autism spectrum disorder are disorders on a continuous spectrum, autism spectrum quotient scores and abbreviated Temperament and Character Inventory scores were expected to be different from normal controls in both disorders in a similar direction. In addition, the autism spectrum quotient and abbreviated Temperament and Character Inventory scores were expected to be closely correlated. These conditions applied to only two of the seven Abbreviated Temperament and Character Inventory scales (harm avoidance and self-directedness), suggesting that temperament and character as an endophenotype of autism spectrum disorder and attention deficit/hyperactivity disorder provides only partial support for the continuity hypothesis of autism spectrum disorder and attention deficit/hyperactivity disorder.

Do candidate genes discriminate patients with an autism spectrum disorder from those with attention deficit/hyperactivity disorder and is there an effect of lifetime substance use disorders?

OBJECTIVE: Autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder (ADHD) are developmental disorders that overlap in a number of domains, sometimes complicating clinical distinction between both disorders. Although there is some evidence for a genetic overlap, there are no reports on genes that could differentiate between ASD and ADHD. Furthermore, it is not known whether this genetic overlap is influenced by co-morbid substance use disorders (SUD). METHODS: A total of 110 adult patients with ASD (n=61) or ADHD (n=49) with or without a lifetime history of SUD participated in a study in which we genotyped polymorphisms in five known candidate genes for (one of) the disorders, i.e. the 5HTTLPR in SLC6A4/5-HTT, rs1800497 (TaqIA C>T) in DRD2, rs7794745 in CNTNAP2, rs1843809 in TPH2, and rs6565113 in CDH13. Genotyping was by Taqman-based analysis or by simple sequence length analysis, where appropriate. RESULTS: ASD could be differentiated from ADHD with nominal statistical significance by the 5HTTLPR, and the polymorphisms in TPH2 and CNTNAP2. The results were independent of lifetime SUD status. CONCLUSIONS: Serotonergic genes could prove to play an important role in differentiating between ASD and ADHD, but the results of this exploratory study need replication.

Treatment seeking adults with autism or ADHD and co-morbid substance use disorder: prevalence, risk factors and functional disability.

BACKGROUND: Little is known about Autism Spectrum Disorder (ASD) in adults, especially not about ASD with co-morbid Substance Use Disorder (SUD). We wanted to examine how adults with ASD compare to adults with ADHD on prevalence and risk factors for co-morbid SUD, and on disability levels associated with SUD. METHODS: We stratified 123 treatment seeking adults with ASD (n=70) or ADHD (n=53), into current, former and no history of SUD (SUD+, SUD(wedge), and SUD-), and conducted interviews to explore associated risk factors and current levels of disability. RESULTS: Prevalence of co-morbid SUD was higher in ADHD than in ASD in our sample (58% versus 30%, p=0.001). There was no statistically significant difference between ASD and ADHD in risk factors or disability scores. Patients with lifetime SUD started regular smoking earlier in life (OR=5.69, C(95%) 2.3-13.8), reported more adverse family events (OR=2.68; CI(95%) 1.2-6.1), and had more parental SUD (OR=5.36; CI(95%) 1.0-14.5). Disability scores were significantly lower in SUD- and SUD(wedge) groups compared to the SUD+ group. DISCUSSION: These findings suggest that ASD and ADHD share similar risk factors for SUD. High disability in ASD and ADHD with SUD may normalize after prolonged abstinence. Early onset of SUD was not associated with more severe disability scores than later onset. Results suggest that a subgroup of patients with former SUD may have a higher level of functioning before the onset of SUD in comparison to those without lifetime SUD.