Pathways to Psychopathology Among Autistic Adults.

PURPOSE OF REVIEW: Autistic adults frequently require treatment of mental health problems. Increased rates of suicidality and diminished quality of life among autistic people may be partially attributable to psychiatric symptoms. Some risk factors for mental health problems in autistic people are likely the same as risk factors present in neurotypical individuals, but unique factors that are specific to neurodivergent individuals, and some even more specific to autistic people, may exist. Understanding pathways from autism to mental health problems could inform intervention efforts at the individual and societal levels. RECENT FINDINGS: We review a growing body of research identifying risk processes across the affective, cognitive, and social domains. Consistent with the principle of equifinality, different processes appear to independently and jointly lead to heightened risk for the onset of mental health problems. Autistic adults frequently utilize mental healthcare services, and experience heightened risk for chronic impairment as a result of mental health problems. Understanding causal and developmental risk processes in autism should inform personalized treatment. We synthesize extant research on these processes and offer suggestions for addressing them therapeutically and societally.

Introduction to the Special Issue: Experimental Therapeutics in Clinical Child and Adolescent Psychology: Identifying Mechanisms and Moving the Needle.

The premise of experimental therapeutics is that one can (a) target a process, or mechanism, underlying psychopathology and (b) that change in said mechanism can cause clinical improvement. Targeting specific mechanisms may permit more effective and personalized medicine. The experimental therapeutics approach holds promise for improving the potency and efficiency of treatments for childhood psychopathology, and for advancing our understanding of the factors that both cause and sustain psychopathology. This special issue presents new research utilizing this framework and offers guidelines for the application of the experimental therapeutics framework.

Sluggish Cognitive Tempo in Autism Spectrum Disorder, ADHD, and Their Comorbidity: Implications for Impairment.

Objective: Sluggish Cognitive Tempo (SCT), characterized by lethargy and daydreaming, has most commonly been studied in community samples and in youth with Attention-Deficit/Hyperactivity Disorder (ADHD). Despite shared neurodevelopmental symptoms with ADHD, few studies have investigated SCT in Autism Spectrum Disorders (ASD). The current study investigated SCT symptoms in youth with ASD, ADHD, and comorbid ASD+ADHD to explore the relations between SCT and global and social impairment.Method: Caregivers of children and adolescents (n = 98; ages 6-17) diagnosed with ADHD (n = 46), ASD (n = 28), or ASD+ADHD (n = 24) completed measures of social impairment, SCT, and demographic variables.Results: All three clinical groups demonstrated comparable levels of SCT. Diagnosis and SCT independently contributed to parent-rated social impairment, while SCT and IQ, but not diagnosis, contributed to clinician-rated global functioning. Specifically, having comorbid ASD+ADHD, but not an ASD or ADHD diagnosis alone, significantly predicted greater social impairment.Conclusion: These results extend previous literature investigating SCT in ASD and provide evidence to suggest that SCT is associated with social and global impairment above and beyond the impairment associated with ADHD and/or ASD. These results may have implications for clinical assessment and treatment of ASD and ADHD.

Facial Affect Sensitivity Training for Young Children with Emerging CU Traits: An Experimental Therapeutics Approach.

OBJECTIVE: This article delineates best practices in the application of the experimental therapeutics framework for evaluating interventions within the context of randomized controlled trials (RCTs), offering a methodological primer and guiding framework for this approach. We illustrate these practices using an ongoing clinical trial conducted within the framework of a National Institute of Mental Health exploratory phased-innovation award for the development of psychosocial therapeutic interventions for mental disorders (R61/R33), describing the implementation of a novel "Facial Affect Sensitivity Training" (FAST) intervention for children with callous-unemotional (CU) traits. CU traits (e.g., lack of guilt or remorse, low empathy, shallow affect) are an established risk factor for persistent and severe youth misconduct, which reflect impairment in identified neurocognitive mechanisms that interfere with child socialization, and predict poor treatment outcomes, even with well-established treatments for disruptive behavior. METHOD: We outline the stages, goals, and best practices for an experimental therapeutics framework. In the FAST trial, we assert that impaired sensitivity for emotional distress cues (fear and/or sadness) is mechanistically linked to CU traits in children, and that by targeting sensitivity to facial affect directly via a computerized automated feedback and incentive system, we can exert downstream effects on CU traits. RESULTS: In the context of an open pilot trial, we found preliminary support for feasibility and mechanism engagement using FAST. CONCLUSIONS: We summarize pilot study limitations and how they are being addressed in the R61/R33 RCTs, as well as challenges and future directions for psychosocial experimental therapeutics.

Neural Mechanisms of Facial Emotion Recognition in Autism: Distinct Roles for Anterior Cingulate and dlPFC.

OBJECTIVE: The present study sought to measure and internally validate neural markers of facial emotion recognition (FER) in adolescents and young adults with ASD to inform targeted intervention. METHOD: We utilized fMRI to measure patterns of brain activity among individuals with ASD (N = 21) and matched controls (CON; N = 20) 2 s prior to judgments about the identity of six distinct facial emotions (happy, sad, angry, surprised, fearful, disgust). RESULTS: Predictive modeling of fMRI data (support vector classification; SVC) identified mechanistic roles for brain regions that forecasted correct and incorrect identification of facial emotion as well as sources of errors over these decisions. BOLD signal activation in bilateral insula, anterior cingulate (ACC) and right dorsolateral prefrontal cortex (dlPFC) preceded accurate FER in both controls and ASD. Predictive modeling utilizing SVC confirmed the utility of ACC in forecasting correct decisions in controls but not ASD, and further indicated that a region within the right dlPFC was the source of a type 1 error signal in ASD (i.e. neural marker reflecting an impending correct judgment followed by an incorrect behavioral response) approximately two seconds prior to emotion judgments during fMRI. CONCLUSIONS: ACC forecasted correct decisions only among control participants. Right dlPFC was the source of a false-positive signal immediately prior to an error about the nature of a facial emotion in adolescents and young adults with ASD, potentially consistent with prior work indicating that dlPFC may play a role in attention to and regulation of emotional experience.

Providers as Stakeholders in Addressing Implementation Barriers to Youth Mental Healthcare.

Research has shown that youth with mental health disorders often do not receive adequate care. School- and community-based mental health organizations are integral to implementing evidence-based mental healthcare to the vast majority of youth. It is therefore important to understand the perspectives of this stakeholder group, to determine how to improve access to high-quality care. A series of three focus groups with community mental health providers and three school counselors and social workers focus groups were conducted to get their perspective on existing barriers that prevent youth who need mental health services from being treated. A grounded theory inductive qualitative analysis revealed six major themes (Lack of Services, Lack of Knowledge, Stigma, Logistics, Poor Past Experiences with Mental Health, and Poor Coordination of Services). Each of these themes are discussed and implications are framed within the context of implementation science.

Improving Transition to Adulthood for Students with Autism: A Randomized Controlled Trial of STEPS.

Emerging adulthood is a period of heightened risk for young people with autism spectrum disorder (ASD). Due in part to a lack of evidence-based services and supports during the transition to adulthood, many emerging adults fail to matriculate into postsecondary education or thrive in productive employment. The Stepped Transition in Education Program for Students with ASD (STEPS) was developed to address the psychosocial, transition-related needs of emerging adults with ASD. Adolescents and emerging adults (n = 59) with ASD were randomly assigned to either STEPS or transition as usual (TAU). Results indicate that STEPS is acceptable to young people with ASD and their parents and that it can be implemented with high fidelity. Among secondary school students, those who completed STEPS exhibited significantly greater gains in transition readiness from high school, and these gains were largely sustained after program completion. Among students enrolled in postsecondary education, STEPS resulted in increased levels of student adaptation to college relative to those in TAU. Programming to address ASD-related challenges can promote successful educational transitions.

Race, gender, and scholarly impact: Disparities for women and faculty of color in clinical psychology.

OBJECTIVE: We sought to determine if gender and race are associated with scientific impact, scholarly productivity, career advancement, and prestige. METHODS: Publicly available data on publications, h-index, advancement, and prestige were assessed across core faculty in all American Psychological Association-accredited clinical psychology programs at R1 institutions in the United States (87 programs, 918 scientists). RESULTS: There were significant effects of both gender and race on productivity and impact, which were most apparent among the most senior faculty. Men and white faculty in associate and full professor ranks had higher scholarly productivity and impact. Among associate professors, men were more likely to get tenure earlier, even when controlling for scientific impact (h-index). Neither gender nor race was associated with prestige among full professors. CONCLUSION: These findings, along with under-representation of non-White faculty across levels (11.2%) and women at the full professor level (42.8%), suggest disparities in academic clinical psychology that must be addressed.

The Under- and Over-Identification of Autism: Factors Associated With Diagnostic Referral.

As reported prevalence and public awareness of Autism Spectrum Disorder (ASD) have grown in recent years, clinicians will likely see increased referrals for suspected ASD. The current study sought to elucidate factors associated with referral for possible ASD, as well as diagnostic outcome among youth referred for suspected ASD. Youth referred for psychological evaluations at an outpatient clinic (N = 69, 6-18 years, 48 male) were categorized into four groups: referred for suspected ASD and diagnosed as such, referred for ASD and not diagnosed as such, not referred for ASD but diagnosed as such, and neither referred for nor diagnosed with ASD. Approximately half of cases referred for suspected ASD did not meet diagnostic criteria. A significant effect of group was found for cognitive ability and anxiety. Youth receiving ASD diagnoses, regardless of whether they were referred for suspected ASD, demonstrated lower cognitive ability than children not receiving ASD diagnoses. Youth neither referred for nor diagnosed with ASD demonstrated lower anxiety than those who were referred and diagnosed. Maternal education significantly differed among the four groups. Although group differences are seen for youth cognitive ability, anxiety, and maternal education, we found no clear indicators differentiating referrals that were "accurate" (i.e., those diagnosed with ASD) and those that were not (i.e., those who did not receive ASD diagnosis). Comorbidity was high in all groups, including those referred primarily for ASD assessment, underscoring the importance of comprehensive assessment regardless of specificity of the referral.

Variability of attention bias in socially anxious adolescents: differences in fixation duration toward adult and adolescent face stimuli.

Prior research on attention bias in anxious youth, often utilising a visual dot probe task, has yielded inconsistent findings, which may be due to how bias is assessed and/or variability in the phenomenon. The present study utilises eye gaze tracking to assess attention bias in socially anxious adolescents, and explores several methodological and within-subject factors that may contribute to variability in attention bias. Attention bias to threat was measured in forty-two treatment-seeking adolescents (age 12-16 years) diagnosed with Social Anxiety Disorder. Bias scores toward emotional stimuli (vigilant attention) and bias scores away from emotional stimuli (avoidant attention) were explored. Bias scores changed between vigilance and avoidance within individuals and over the course of stimulus presentation. These differences were not associated with participant characteristics nor with self-reported social anxiety symptoms. However, clinician rated severity of social anxiety, explained a significant proportion of variance in the bias scores for adult, but not the adolescent, stimuli. Variability in attention bias among socially anxious adolescents is common and varies as a function of stimulus duration and type. Results may inform stimulus selection for future research.

Change in gaze-based attention bias in adolescents with Social Anxiety Disorder.

Although attention bias (AB) toward threat has been associated with Social Anxiety Disorder (SAD), concerns regarding the ability of current measures to detect change in AB following treatment exist. We sought to examine change in bias, as measured via eye-tracking, in adolescents with SAD receiving either attention-bias modification training (ABMT) or attention-control training (ACT). Gaze-based AB was associated (r = -0.361) with symptoms of social anxiety prior to treatment, whereas there was no association between bias as measured via dot probe and social anxiety. Moreover, gaze-based bias to same-age face stimuli showed change following treatment. Large effects are seen for condition (ABMT or ACT) and for time, independent of treatment condition, in gaze-based AB to same-age stimuli. Findings suggest that further research on gaze-based bias, to assess stability over time outside of treatment and sensitivity to change following intervention, is warranted.

Psychosocial Treatments Targeting Anxiety and Depression in Adolescents and Adults on the Autism Spectrum: Review of the Latest Research and Recommended Future Directions.

PURPOSE OF REVIEW: This synthesis of treatment research related to anxiety and depression in adolescents and adults with autism spectrum disorder (ASD) focuses on the scientific support for various forms of psychosocial interventions, useful adaptations to standard interventions, and engagement of candidate therapeutic mechanisms. RECENT FINDINGS: There is considerable evidence for the efficacy of cognitive-behavioral therapy (CBT) to treat co-occurring problems with anxiety, but there has been relatively little research on treatment of co-occurring depression. Multiple mechanisms of treatment effect have been proposed, but there has been little demonstration of target engagement via experimental therapeutics. Comorbidity between ASD and anxiety and/or mood problems is common. Although there is evidence for the use of CBT for anxiety, little work has addressed how to effectively treat depression. There is emerging support for alternative treatment approaches, such as mindfulness-based interventions. We encourage rigorous, collaborative approaches to identify and manipulate putative mechanisms of change.

Psychosocial interventions for internalizing disorders in youth and adults with ASD.

Internalizing disorders are common in individuals with ASD. Psychosocial interventions targeting these disorders in the ASD population have burgeoned in the last decade. Cognitive-behavioural therapy, modified for ASD, is the most frequently investigated model, although other interventions, including behaviour therapy, third-wave interventions, models targeting transdiagnostic constructs, and alternative interventions and treatment delivery methods are now emerging. This review provides a summary of the efficacy of these interventions in treating internalizing disorders in youth and adults with ASD. The barriers to accessing these treatments, which are experienced by many individuals with ASD and their families, as well as future research directions, are also discussed.

The Influence of Social Communication Impairments on Gaze in Adolescents with Social Anxiety Disorder.

Adolescents with social anxiety disorder (SAD) often present distorted beliefs related to expected social rejection, coupled with avoidance of social stimuli including interpersonal interactions and others' gaze. Social communication (SC) deficits, often seen in SAD, may play a role in avoidance of social stimuli. The present study evaluated whether SC impairment uniquely contributes to diminished or heightened attention to social stimuli. Gaze patterns to social stimuli were examined in a sample of 41 adolescents with SAD (12-16 years of age; 68% female). Unexpectedly, no significant relationship was observed between SC impairment and fixation duration to angry or neutral faces. However, SC impairment did predict greater fixation duration to happy faces, after controlling for social anxiety severity [adjusted R 2 = 0.201, F(2, 38) = 4.536, p = 0.018]. Clinical implications are discussed, focusing on the potential utility of targeting SC impairments directly in light of the role of SC difficulties in youth with SAD.

The impact of rape acknowledgment on survivor outcomes: The moderating effects of rape myth acceptance.

OBJECTIVE: Little is known about how rape acknowledgment relates to posttrauma functioning; recent research suggests the effect may depend on additional factors. In the current study, the moderating effect of rape myth acceptance (RMA) on the relationships between rape acknowledgment and mental health outcomes was examined. METHOD: A sample of 181 female rape survivors recruited from a university completed an online survey assessing RMA, rape acknowledgment, depression symptoms, and alcohol use. RESULTS: Generally, the results supported that RMA moderated the influence of rape acknowledgment on depression symptoms and average quantity per drinking episode, but not frequency of alcohol use. The findings demonstrated that when individuals endorsed high levels of RMA, acknowledged rape survivors reported worse outcomes than unacknowledged rape survivors. Among individuals low on RMA, unacknowledged rape survivors reported worse outcomes than acknowledged rape survivors. CONCLUSION: It is recommended that clinicians recognize the role of survivor beliefs, such as RMA, in the relationship between labeling sexual assault experiences and mental health consequences.

Eye-Gaze Analysis of Facial Emotion Recognition and Expression in Adolescents with ASD.

Impaired emotion recognition and expression in individuals with autism spectrum disorder (ASD) may contribute to observed social impairment. The aim of this study was to examine the role of visual attention directed toward nonsocial aspects of a scene as a possible mechanism underlying recognition and expressive ability deficiency in ASD. One recognition and two expression tasks were administered. Recognition was assessed in force-choice paradigm, and expression was assessed during scripted and free-choice response (in response to emotional stimuli) tasks in youth with ASD (n = 20) and an age-matched sample of typically developing youth (n = 20). During stimulus presentation prior to response in each task, participants' eye gaze was tracked. Youth with ASD were less accurate at identifying disgust and sadness in the recognition task. They fixated less to the eye region of stimuli showing surprise. A group difference was found during the free-choice response task, such that those with ASD expressed emotion less clearly but not during the scripted task. Results suggest altered eye gaze to the mouth region but not the eye region as a candidate mechanism for decreased ability to recognize or express emotion. Findings inform our understanding of the association between social attention and emotion recognition and expression deficits.

ASD Traits Among Youth with Obsessive-Compulsive Disorder.

Research has shown high rates of comorbid psychiatric disorders among samples of youth with obsessive-compulsive disorder (OCD) (Farrell et al., Psychiatry Res 199(2):115-123, 2012; Lewin et al., Psychiatry Res 178(2):317-322, 2010; POTS Team, J Am Med Assoc 292(16):1969-1976, 2004). Autism and autistic traits co-occur at high rates within clinical samples of youth with OCD (Ivarsson and Melin in J Anxiety Disord 22(6):969-978, 2008; Stewart et al. in Child Psychiatry Hum Dev 1-9, 2016). This study extends the literature by examining the relationship between ASD traits, family accommodation, and functional impairment in a sample of youth with OCD across a wide age range (n = 80; aged 7-17 years). Results indicated that autistic traits, as measured by the social responsiveness scale (SRS), were elevated in 32.5% of youth (based on a T-score of 66T and above) relative to typically developing youth, as well as youth with non-autism-related psychiatric disorders (Constantino and Gruber in Social responsiveness scale, Western Psychogical Services, Torrance, 2012). Furthermore, 27.5% of youth scored within a moderate range (66T-75T) and 5% of youth scored within a severe range (76T or higher) on the SRS, typical of children with ASD (Constantino and Gruber in Social responsiveness scale, Western Psychogical Services, Torrance, 2012). Additionally, ASD traits were associated with greater functional impairment above OCD severity. Furthermore, family accommodation mediated the relationship between ASD traits and functional impairment. Implications of these findings are discussed in the context of clinical assessment and direction for further research.

Primary Versus Secondary Diagnosis of Generalized Anxiety Disorder in Youth: Is the Distinction an Important One?

Examine whether children with a primary diagnosis of generalized anxiety disorder (GAD) differ from children with a secondary diagnosis of GAD on clinician, parent, teacher, and youth-report measures. Based on consensus diagnoses, 64 youth referred to a general outpatient assessment clinic were categorized as having either a primary or secondary diagnosis of GAD. A semi-structured diagnostic interview was used to guide diagnostic decisions and assign primary versus secondary diagnostic status. We predicted that youth with a primary GAD diagnosis would present with greater anxiety symptomatology and symptom impairment on a variety of anxiety-related measures than youth with a secondary GAD diagnosis. Contrary to our hypotheses, no differences were found between those with primary versus secondary GAD diagnoses on measures of symptom severity and clinical impairment, comorbid diagnoses, or youth and teacher-report measures. Our findings have potential implications for the current practice of requiring primary anxiety diagnostic status as an inclusion criterion in clinical research and treatment outcome studies. Assuming our findings are confirmed in larger samples and with other anxiety disorders, future clinical trials and basic psychopathology research might not exclude youth based on absence of a particular anxiety disorder as the primary disorder but rather include individuals for whom that anxiety disorder is secondary as well.

Effects of Verbal Ability and Severity of Autism on Anxiety in Adolescents With ASD: One-Year Follow-Up After Cognitive Behavioral Therapy.

There is evidence supporting the efficacy of cognitive-behavioral therapy for treatment of anxiety in youth with Autism Spectrum Disorders (ASD), but long-term course of anxiety after treatment and individual predictors of treatment response are unknown. To meet the demands for personalized mental health care, information on the fit between patient and treatment as well as treatment durability is needed. We evaluated change in anxiety symptoms during intervention and 1 year after completion of the treatment, and evaluated predictors of response using an advanced analytical design, with follow-up data from a randomized controlled trial of 22 adolescents (12-17 years) with ASD and 1 or more anxiety disorders. Reduction in anxiety was partially maintained during the year following treatment; greater ASD severity predicted better treatment response. Our finding that brief treatment is associated with sustained gains is promising, given the pervasive and chronic nature of ASD. Implications for the treatment of anxiety in higher functioning adolescents with ASD are considered.