A Parent-Mediated Anxiety Intervention Specifically Tailored for Autistic Preschoolers: A Pilot Study.

IMPORTANCE: Autistic children experience reduced participation in life activities. One factor that may contribute to their reduced levels of participation is anxiety, which is identified at higher rates among young autistic children than among their neurotypical peers. Anxiety is also strongly associated with sensory overresponsivity and has a considerable impact on daily functioning. OBJECTIVE: To determine the feasibility, acceptability, and usefulness of a small-group, parent-mediated intervention to prevent and reduce anxiety. DESIGN: Pre-post. SETTING: University research center. PARTICIPANTS: Three parents of autistic children (ages 4-7 yr). OUTCOMES AND MEASURES: Parents completed a six-session group training program. Parents completed an anxiety scale for their child before and after parent training. At the end of training, parents participated in a focus group and were interviewed 4 mo after training. RESULTS: Positively received aspects of the intervention were the benefits of a small group, composed of parents of autistic children, run by a facilitator with expertise in autism and anxiety. Parents gained knowledge, resulting in "taking a different approach" with their child and "seeing an interplay between anxiety and autism." After the intervention, parents reported a reduction in children's reported anxiety levels. CONCLUSIONS AND RELEVANCE: Knowledge of autism and anxiety acquired during a parent-mediated group increased parents' understanding of their child's behaviors and assisted them in supporting their child's participation. Further research, including larger studies, is required to determine the effectiveness of this intervention. What This Article Adds: The findings from this research provide preliminary support for the adaptation of an existing parent intervention (Cool Little Kids) to reduce anxiety among autistic children. Parents reported an increased awareness and understanding of anxiety and of the interplay between anxiety and autistic traits. Positionality Statement: This article uses the identity-first language autistic people. This nonableist language describes their strengths and abilities and is a conscious decision. This language is favored by autistic communities and self-advocates and has been adopted by health care professionals and researchers (Bottema-Beutel et al., 2021; Kenny et al., 2016).

Autism and autistic traits in those who died by suicide in England.

BACKGROUND: Autism and autistic traits are risk factors for suicidal behaviour. AIMS: To explore the prevalence of autism (diagnosed and undiagnosed) in those who died by suicide, and identify risk factors for suicide in this group. METHOD: Stage 1: 372 coroners' inquest records, covering the period 1 January 2014 to 31 December 2017 from two regions of England, were analysed for evidence that the person who died had diagnosed autism or undiagnosed possible autism (elevated autistic traits), and identified risk markers. Stage 2: 29 follow-up interviews with the next of kin of those who died gathered further evidence of autism and autistic traits using validated autism screening and diagnostic tools. RESULTS: Stage 1: evidence of autism (10.8%) was significantly higher in those who died by suicide than the 1.1% prevalence expected in the UK general alive population (odds ratio (OR) = 11.08, 95% CI 3.92-31.31). Stage 2: 5 (17.2%) of the follow-up sample had evidence of autism identified from the coroners' records in stage 1. We identified evidence of undiagnosed possible autism in an additional 7 (24.1%) individuals, giving a total of 12 (41.4%); significantly higher than expected in the general alive population (1.1%) (OR = 19.76, 95% CI 2.36-165.84). Characteristics of those who died were largely similar regardless of evidence of autism, with groups experiencing a comparably high number of multiple risk markers before they died. CONCLUSIONS: Elevated autistic traits are significantly over-represented in those who die by suicide.

Commentary: Thinking flexibly about mental health and autism - a commentary on Ozsivadjian et al. (2020).

Research on mental health in autism has quite rightly flourished over the past fifteen years, and there is now clear evidence that autistic people are at heightened risk of experiencing mental health concerns. Recent research has shown that common mental health conditions may be experienced differently by autistic people, meaning that assessment and intervention techniques that were developed with and for neurotypical individuals are potentially less sensitive and effective for those on the spectrum. The upshot of this work is that we need to get better at all of these aspects of identification, support and intervention and that will only be possible with a clear understanding of the mechanisms of mental distress for autistic people. The work described in Ozsivadjian et al. (2020) makes a welcome addition to this literature. In this commentary, we explore the strengths and limitations of the work and consider its contribution to research and clinical practice in the field of autism and mental health.

The relationship between the therapeutic alliance and clinical outcomes in cognitive behaviour therapy for adults with depression: A meta-analytic review.

Research consistently provides evidence for the relationship between the therapeutic alliance (TA) and outcome across various therapies and presenting problems. Depression is considered the leading cause of disability worldwide, and there is substantial evidence for the efficacy for Cognitive Behaviour Therapy (CBT) in its treatment. At present, there is lack of clarity specifically about the relationship between the TA and outcome in CBT for depression. The present review is the first meta-analytic review to explore this relationship and also considering moderators. Within a random-effects model, an overall mean effect size of r = 0.26 (95% CI [.19-.32]) was found, indicating that the TA was moderately related to outcome in CBT for depression. The mean TA-outcome correlation is consistent with existing meta-analysis that looked across a broad range of presenting problems and psychological therapies. A secondary exploratory analysis of moderators suggested the TA-outcome relationship varied according to the TA rater, where the relationship was weaker for therapist raters compared with clients and observer raters. Additionally, the results indicated that the TA-outcome relationship marginally increased over the course of CBT treatment. The results of the meta-analysis are discussed in reference to the wider body of research, methodological limitations, clinical implications, and future directions for research.

Facing the Unknown: Intolerance of Uncertainty in Children with Autism Spectrum Disorder.

BACKGROUND: Anxiety is a common problem for children with autism spectrum disorder (ASD). Recent research indicates that intolerance of uncertainty (IU) may be an important aspect of anxiety for this population. IU is the belief that uncertainty is upsetting, and not knowing what is going to happen is negative. There is little known about the phenomenology of IU in children with ASD. We therefore present data from parent focus groups exploring this concept in children with ASD. METHODS: Participants were asked to differentiate IU from dislike of change and fear, and to discuss examples of IU and the strategies they use to manage it. Their experiences of IU and strategies are presented. RESULTS: IU was evident across novel and familiar situations and parents used a variety of strategies to manage IU. Their experiences of IU and strategies used are presented. CONCLUSIONS: Participants were able to identify and provide examples of IU suggesting that it is a recognizable construct among children with ASD.

Exploring Carers' Judgements of Responsibility and Control in Response to the Challenging Behaviour of People with Intellectual Disabilities.

BACKGROUND: This study examines Weiner's recent cognitive emotional model which makes a distinction between judgements of control and responsibility and emphasizes the moderation of control by 'mitigating' factors. METHOD: In response to four vignettes describing two conditions of control (high or low) and mitigating factors (present or absent), questionnaires rating judgements of responsibility and emotional responses (anger and sympathy) were completed by 52 care staff. RESULTS: Analysis of the data for sympathy demonstrated that attributions of control were moderated by communication ability and that the effect of control upon sympathy was mediated by the judgement of responsibility. CONCLUSIONS: The data offer tentative support Weiner's account of the mitigation of control attributions in making responsibility judgements and their subsequent effects on emotional responses. Implications for research and clinical work are discussed.

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

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

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.

The development of the Helping your Anxious Child programme: a parent-mediated group intervention for parents of autistic children in South Asia.

Autistic children are at increased risk of experiencing a range of mental health difficulties, including anxiety. A number of intervention programmes are now available in high-income countries to support autistic children. However, to date there are no evidence-based interventions to support families of such children in South Asia. Based on consultations with clinicians, researchers and parents in Bangladesh and Sri Lanka, we developed a culturally tailored two-session skills-based group programme for parents whose autistic children present with anxiety. This paper describes the process of creating this programme, to be delivered by mental health professionals.

Feasibility and acceptability of autism adapted safety plans: an external pilot randomised controlled trial.

Background: Autistic people are a high-risk group for self-harm and suicide. There are no evidence-based suicide prevention interventions developed specifically for autistic people. We undertook a pilot feasibility randomised controlled trial of autism adapted safety plans (AASP) to reduce self-harm and suicide for autistic people. Methods: This study took place in the United Kingdom and followed a randomised, two-arm, controlled design. Autistic adults (n = 53, mean age = 39, gender = 49% female, 29% not male or female) were recruited via third sector organisations and self-referral between 11.8.21 and 19.10.22. Participants were randomised without stratification to usual care with or without AASP. The AASP was completed by the autistic adults together with someone trained to support them. Research staff who completed follow-up assessments were blind to participant allocation. Primary outcomes were feasibility and acceptability. Participants were assessed at baseline, 1 and 6 months. Primary data were analysed under the intention to treat principle. Study protocol is published. The trial is closed to new participants. This study is registered with the ISRCTN registry, ISRCTN70594445. Findings: 53 participants consented, 49 were randomised to either AASP with usual care (n = 25) or usual care (n = 24). 68% of participants in the AASP arm were satisfied with the AASP and 41% rated it as useable. Feedback on the AASP and research methods were positive with suggested adaptations to some outcome measures. Retention and completion of outcomes measures in both arms was excellent, as was fidelity of delivery of the AASP. Interpretation: Study progression criteria were met, suggesting that the parameters of a future definitive trial of clinical and cost effectiveness of AASP to reduce self-harm and suicide in autistic adults are achievable, with minor recommended adaptions to outcome measures and AASP. Future research should explore the use of AASP in routine clinical practice. Funding: This study is funded by the NIHR [Public Health Research Programme (NIHR129196)].

Is camouflaging autistic traits associated with defeat, entrapment, and lifetime suicidal thoughts? Expanding the Integrated Motivational Volitional Model of Suicide.

INTRODUCTION: The current study explored whether camouflaging autistic traits is associated with defeat and entrapment and lifetime suicidal thoughts, as predicted by the Integrated Volitional Model of Suicide (IMV model). METHODS: 180 UK undergraduate students (76.7% female 18-67 years) completed a cross-sectional online survey from February 5 to March 23, 2020, including self-report measures of defeat and entrapment (SDES), autistic traits (AQ-10), depression (PHQ-9), anxiety (GAD-7), camouflaging autistic traits (CAT-Q), and lifetime suicidal thoughts and behaviors (SBQ-R item 1). RESULTS: After controlling for age, gender, current depression, and anxiety symptoms, autistic traits accounted for significantly more of the variance in defeat and entrapment (1.1%), and camouflaging accounted for a further 3.2% of the variance. The association between autistic traits and lifetime suicidality was significantly mediated by camouflaging, defeat, and entrapment. After controlling for age, gender, current depression, and anxiety symptoms, defeat and entrapment (but not camouflaging) accounted for significantly more variance in lifetime suicidal thoughts. The interaction between camouflaging, defeat and entrapment predicted significantly less variance in lifetime suicidal thoughts than either variable alone. CONCLUSION: Results suggest that camouflaging autistic traits is a transdiagnostic risk factor for lifetime suicidality, relevant to the defeat and entrapment constructs of the IMV model.

The role of anxiety and depression in suicidal thoughts for autistic and non-autistic people: A theory-driven network analysis.

BACKGROUND: Autistic adults experience more frequent suicidal thoughts and mental health difficulties than non-autistic adults, but research has yet to explain how these experiences are connected. This study explored how anxiety and depression contribute to suicidal thoughts according to the Interpersonal Theory of Suicide for autistic and non-autistic adults. METHODS: Participants (autistic adults n = 463, 61% female; non-autistic n = 342, 64% female) completed online measures of anxiety, depression, thwarted belonging, and perceived burdensomeness. Network analysis explored whether: (i) being autistic is a risk marker for suicide; and (ii) pathways to suicidal thoughts are consistent for autistic and non-autistic adults. RESULTS: Being autistic connected closely with feeling like an outsider, anxiety, and movement, which connected to suicidal thoughts through somatic experiences, low mood, and burdensomeness. Networks were largely consistent for autistic and non-autistic people, but connections from mood symptoms to somatic and thwarted belonging experiences were absent for autistic adults. CONCLUSION: Autistic people experience more life stressors than non-autistic people leading to reduced coping, low mood, and suicidal thoughts. Promoting belonging, reducing anxiety, and understanding the role of movement could inform suicide prevention for autistic people. Research should accurately capture autistic lived experience when modeling suicide to ensure suicide prevention meets autistic needs.

A Pilot Randomised Control Trial Exploring the Feasibility and Acceptability of Delivering a Personalised Modular Psychological Intervention for Anxiety Experienced by Autistic Adults: Personalised Anxiety Treatment-Autism (PAT-A).

Anxiety is commonly experienced by autistic people and impacts on quality of life and social participation. New anxiety interventions are required to effectively meet the needs of autistic people. Personalised Anxiety Treatment-Autism (PAT-A©) is a bespoke, modular approach to treating anxiety in up to 12 sessions. This study explored the feasibility and acceptability of delivering PAT-A© in the UK National Health Service (NHS). A single-blind randomised controlled trial design. Thirty-four autistic adults were recruited via clinical services and randomised to receive either PAT-A© or enhanced treatment as usual (CCSP). Outcome assessments relating to anxiety, quality of life and related constructs were completed at baseline, immediately post intervention; and at 3 and 12 months. Seventy-one percent of the PAT-A© group and 65% of the CCSP met diagnostic threshold for at least three anxiety disorders. Retention was good across both groups, with 82% (N = 14/17) completing the full course of PAT-A© and 71% (N = 12/17) attending both psychoeducational sessions in CCSP. 94% in PAT-A© and 82% in CCSP completed some follow up assessment 3 months post-intervention. Thematic analysis of interview data revealed that many participants valued the personalised approach, developed transferable skills and experienced positive changes to their anxiety. Participants were willing to be recruited and randomised, PAT-A© was feasible to deliver in the NHS and the trial methods and materials were acceptable. Our findings indicate that a fully powered clinical and cost-effectiveness trial of PAT-A© is warranted.

Lived experiences of depression in autistic children and adolescents: A qualitative study on child and parent perspectives.

BACKGROUND: Depression is highly prevalent in autistic children and adolescents. Despite this, little is known about the nature of the autistic child's subjective experience of depression and the impact of depression on their lives. METHODS: We therefore conducted a qualitative study using thematic analysis with 7 autistic children and adolescents and their parents to identify common themes and individual differences. All children had previously experienced at least one depressive episode. RESULTS: Six main themes were identified: (1) Autism related experiences; (2) Difficulties with peer relationships; (3) Co-occurring relationships between anxiety and depression; (4) Impactful pessimism and anhedonia; (5) Impactful difficulties with focus and concentration and (6) Feelings of irritability, including aggressive behaviours. Parent's accounts of their children's experience of depression mirrored the child's perspective. Novel findings included reports of depression related restriction of diet variety and masking of mental health difficulties. Children and parents linked being autistic and developing depression, referring to the difficulties of being autistic in a complex, neurotypical world. CONCLUSIONS: These results highlight key challenges that autistic children and their families experience, calling for increased awareness of the impact of depression on autistic young people.

Coping with uncertainty in everyday situations (CUES©) to address intolerance of uncertainty in autistic children: an intervention feasibility trial.

BACKGROUND: Anxiety related to uncertainty is common in autism. Coping with Uncertainty in Everyday Situations (CUES©) is a parent-mediated group intervention aiming to increase autistic children's tolerance to uncertain situations. A pilot study was conducted to test its feasibility and acceptability. METHODS: Parents of 50 autistic children were randomised to receive CUES© or enhanced services as usual. RESULTS: All children met the clinical threshold for at least one anxiety disorder. Of the 26 participants randomised to CUES©, 72% attended 4-8 sessions. Parents and therapists reported they found CUES© useful and acceptable. CONCLUSIONS: Families were willing to be recruited and randomised, the format/content was feasible to deliver, and the outcome measures were acceptable. CUES© should be evaluated in a clinical and cost effectiveness randomised controlled trial.

Adapted suicide safety plans to address self-harm, suicidal ideation, and suicide behaviours in autistic adults: protocol for a pilot randomised controlled trial.

BACKGROUND: Suicide prevention is a national priority for the UK government. Autistic people are at greater risk of experiencing self-harm and suicidal thoughts and behaviours than the general population. Safety plans are widely used in suicide prevention but have not yet been designed with and for autistic people. We developed the first safety plan specifically targeting suicidality in autistic adults: the Autism Adapted Safety Plan (AASP). It consists of a prioritised list of hierarchical steps that can be used prior to or during a crisis to mitigate risk of self-harm and suicidal behaviour. This is a pilot study that aims to assess the feasibility and acceptability of the AASPs and the research processes, including the response rates, potential barriers and reach of AASPs, methods of recruitment, what comprises usual care, and economic evaluation methods/tools. METHODS: This is an external pilot randomised controlled trial of a suicide prevention tool aimed at mitigating the risk of self-harm and suicidal behaviour in autistic adults: AASPs. Participants will be assessed at baseline and followed up 1 month and 6 months later. Assessments include questions about self-harm, suicidality, service use, and their experience of the AASP/taking part in the study. Autistic adults who have a clinical autism diagnosis and self-reported history of self-harm, suicidal thoughts, or suicidal behaviours within the last 6 months will be invited to take part in the study. Informed consent will be obtained. Participants will be recruited via community and third sector services (including community settings, autism charities, and mental health charities). They may also "self-refer" into the study through social media recruitment and word of mouth. Ninety participants will be randomised to either develop an AASP or receive their usual care in a 1:1 ratio. DISCUSSION: The present study will provide an evaluation of the suitability of the processes that would be undertaken in a larger definitive study, including recruitment, randomisation, methods, questionnaires, outcome measures, treatment, and follow-up assessments. TRIAL REGISTRATION: ISRCTN70594445, Protocol v4: 8/2/22.

Attenuation of change blindness in children with autism spectrum disorders.

Change blindness refers to the difficulty most people find in detecting a difference between two pictures when these are presented successively, with a brief interruption between. Attention at the site of the change is required for detection. A number of studies have investigated change blindness in adults and children with autism spectrum disorders (ASD). Some have produced evidence that people with ASD find changes to social stimuli harder to detect and changes to non-social stimuli easier to detect, relative to comparison participants. However, other studies have produced entirely contradictory findings. There is a need for consistency in methodology to aid understanding of change blindness and attentional processes in ASD. Here, we replicate a change blindness study previously carried out with typically developing (TD) children and adults and with adults with ASD. Results reveal attenuated change blindness for non-social stimuli in children with ASD relative to TD norms. Our results are interpreted, alongside others' findings, as potentially indicative of a complex relationship between different influences on attention over time.

Changes in attributions as a consequence of training for challenging and complex behaviour for carers of people with learning disabilities: a systematic review.

AIM: This paper reviews the evidence for changes in carers' attributions regarding the behaviour of people with intellectual disabilities as a consequence of carer training in challenging and complex behaviour. METHOD: Papers were included in the review if they reported outcomes for carer training on the behaviour of people with intellectual disabilities and used a measure of carer attribution of the behaviour of people with intellectual disabilities. The characteristics of the scales used and the content and length of training are considered as possible factors affecting changes in attribution. RESULTS: Eleven papers were reviewed, most studies using behavioural curricula for their training, and none explicitly set out to change attributions. Eight of the 11 papers reviewed reported changes in attribution although core characteristics of training did not distinguish those papers that reported such changes and those that did not. CONCLUSIONS: Changes in beliefs and attributions occur even though these are not identified as a focus within the training provided. The present authors suggest that the formulation processes involved in behavioural training may play a key part in changing attributions as a consequence of this training. The present authors discuss the potential for more focussed intervention designed to change attributions and for better alignment of measures to specific attribution change expected as a result of specific training approaches.

Re: Caron et al., 2021, sociocultural context and autistics quality of life: A comparison between Quebec and France.

LAY ABSTRACT: This letter to the editors discusses the use of the ASQoL for research with autistic adults. The autism quality of life measure was developed for use alongside two existing measures of quality of life developed by the World Health Organization. It was not developed as a questionnaire to be used in its own. The letter raises some concerns about the use of the autism quality of life measure as a standalone measure in a recent study by Caron et al., published in Autism.

The Mediating Effects of Alexithymia, Intolerance of Uncertainty, and Anxiety on the Relationship Between Sensory Processing Differences and Restricted and Repetitive Behaviours in Autistic Adults.

Distress caused by sensory processing differences for autistic individuals may be reduced by repetitive behaviours (RRB), including repetitive motor (RMB) and insistence on sameness (ISB) behaviours. Intolerance of uncertainty (IU) and anxiety mediate the relationship between sensory processing and RRB in autistic children. We replicated this model in autistic adults, extending it to include alexithymia. Serial mediation, using data from 426 autistic adults, identified significant direct effects from sensory processing to RMB and ISB, and indirect effects through alexithymia-IU-anxiety for RMB, and IU alone, and alexithymia-IU for ISB. Different mechanisms may underpin RMB and ISB. Alexithymia alongside, IU and anxiety, should be considered when understanding the relationship between sensory processing and RRB, and when offering interventions to support autistic people.