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Challenging behavior, such as aggression, is highly prevalent in children and adolescents with autism and can have a devastating impact. Previous reviews of challenging behavior interventions did not include interventions targeting emotion dysregulation, a common cause of challenging behavior. We reviewed emotion dysregulation and challenging behavior interventions for preschoolers to adolescents to determine which evidence-based strategies have the most empirical support for reducing/preventing emotion dysregulation/challenging behavior. We reviewed 95 studies, including 29 group and 66 single-case designs. We excluded non-behavioral/psychosocial interventions and those targeting internalizing symptoms only. We applied a coding system to identify discrete strategies based on autism practice guidelines with the addition of strategies common in childhood mental health disorders, and an evidence grading system. Strategies with the highest quality evidence (multiple randomized controlled trials with low bias risk) were Parent-Implemented Intervention, Emotion Regulation Training, Reinforcement, Visual Supports, Cognitive Behavioral/Instructional Strategies and Antecedent-Based Interventions. Regarding outcomes, most studies included challenging behaviors measures while few included emotion dysregulation measures. This review highlights the importance of teaching emotion-regulation skills explicitly, positively reinforcing replacement/alternative behaviors, using visuals and metacognition, addressing stressors proactively, and involving parents. It also calls for more rigorously-designed studies and for including emotion dysregulation as an outcome/mediator in future trials.

Challenges with emotion dysregulation, self-injurious behavior (SIB), and aggression are common in autistic individuals. Prior research on the relationships between these behaviors is limited mainly to cross-sectional correlations of parent-report data. Understanding how emotion dysregulation, SIB, and aggression present and relate to one another in real-time could add to our understanding of the context and function of these behaviors. The present study examined the real-time occurrence and temporal relationships between these behaviors in 53 psychiatrically hospitalized autistic youth. Over 500 hours of behavioral observation occurred during everyday activities in the hospital. Start and stop times for instances of overt emotion dysregulation, SIB, and aggression were coded live using a custom mobile phone app. Results indicated large individual variability in the frequency and duration of these behaviors and their co-occurrence. Both SIB and aggression co-occurred with overt emotion dysregulation at above-chance levels, suggesting a role for emotional distress in the occurrence of these behaviors. However, there was substantial variability within and between individuals in co-occurrence, and SIB and aggression often (and for some individuals, almost always) occurred without overt emotion dysregulation. Relatedly, cross-recurrence quantitative analysis revealed that SIB and aggression preceded emotion dysregulation more often than emotion dysregulation preceded SIB and aggression. Future research, perhaps using ambulatory psychophysiological measures, is needed to understand whether emotion dysregulation may sometimes be present but not easily observed during SIB and aggression. LAY SUMMARY: This study provides insight into how overt emotion dysregulation (i.e., visible distress), aggression, and self-injury unfold in real-time for autistic individuals. Participants were 53 autistic youth staying in a psychiatric hospital. Research staff observed participants in everyday activities on the hospital unit and noted instances of aggression, self-injurious behavior, and emotion dysregulation. Results suggest that aggression and self-injury sometimes occur with visible signs of distress but also often occur without visible distress. In addition, observable distress was more common in the moments after these behaviors than in the moments before.

Emotion dysregulation (ED) underlies psychiatric symptoms and impedes adaptive responses in autistic individuals. The Emotion Awareness and Skills Enhancement (EASE) program was the first mindfulness-based intervention designed to target emotion dysregulation in autistic adolescents (12–17 years old). This project partnered with stakeholders to adapt EASE for autistic adolescents and adults with co-occurring intellectual disability and autistic elementary-aged children, groups who often benefit from caregiver support in treatment. Over three adaptation phases, we: (1) elicited stakeholder and expert feedback to adapt the original EASE program for autistic individuals with intellectual disability; (2) redesigned the adapted manual and expanded the target age range following a small “micro-trial” with a sample of autistic adolescents and adults with intellectual disability ( n = 6); and (3) demonstrated feasibility and acceptability of a caregiver-client team-based approach (EASE-Teams) in a sample of 10 autistic individuals with and without intellectual disability (ages 7–25) and their caregivers. EASE-Teams was both acceptable and helpful to families. Significant improvements were noted in participant emotion dysregulation, psychiatric symptoms, and caregiver stress from their child’s dysregulation. Findings suggest that EASE-Teams may be appropriate for heterogeneous developmental and cognitive needs. Future research to establish efficacy and refine EASE-Teams with community providers is warranted. Lay abstract Emotion dysregulation (ED) impacts mental health symptoms and well-being in autistic individuals. In prior work, we developed the Emotion Awareness and Skills Enhancement (EASE) to improve emotion dysregulation with autistic adolescents (aged 12–17). The study team partnered with autistic individuals, their caregivers, and expert clinicians to adapt EASE for autistic adolescents and adults with co-occurring intellectual disability and autistic elementary-aged children, groups that often benefit from caregiver support in treatment. In three phases, we (1) gathered caregiver and expert feedback to adapt the original EASE program for autistic adults with intellectual disability, (2) revised the treatment after using it with six autistic adults with intellectual disability, and (3) tested the newly developed caregiver–client team-based treatment, called EASE-Teams, in a small group of 10 autistic individuals with and without intellectual disability (aged 7–25). Families found EASE-Teams to be acceptable and helpful. We found improvements in emotion dysregulation and mental health symptoms for autistic participants. Caregivers reported less stress from their child’s dysregulation after participating. These results show that EASE-Teams can be appropriate for different developmental and cognitive needs. Future studies will need to test the benefits of the treatment in community clinics.

BACKGROUND As many as 80% of children on the autism spectrum exhibit challenging behaviors (i.e., behaviors dangerous to the self or others, behaviors that interfere with learning and development, and/or behaviors that interfere with socialization) that can have a devastating impact on personal and family well-being, contribute to teacher burnout, and even require hospitalization. Evidence-based practices to reduce these behaviors emphasize identifying triggers (events or antecedents that lead to challenging behaviors), yet parents and teachers often report that challenging behaviors surface with little warning. Exciting recent advances in biometric sensing and mobile computing technology allow measurement of momentary emotion dysregulation using physiological indices. OBJECTIVE We present the framework and protocol for a pilot trial that will test a mobile digital mental health application, the KeepCalm app. School-based approaches to managing challenging behaviors in children on the autism spectrum are limited by three key factors: 1) children on the autism spectrum often have difficulties communicating their emotions; 2) it is challenging to implement evidence-based, personalized strategies for individual children in group settings; and 3) it is difficult for teachers to track which strategies are successful for each child. KeepCalm aims to address those barriers by 1) communicating children’s stress to their teachers using physiological signaling (emotion dysregulation detection); 2) supporting implementation of emotion regulation strategies via smartphone pop-up notifications of top strategies for each child per behavior (emotion regulation strategy implementation); and 3) easing the burden of tracking outcomes by providing the child’s educational team with a tool to track the most effective emotion regulation strategies for that child based on physiological stress reduction data (emotion regulation strategy evaluation). METHODS We will test KeepCalm with 20 educational teams of students on the autism spectrum with challenging behaviors (no exclusion based on IQ or speaking ability) in a pilot randomized waitlist-controlled field trial over a 3-month period. We will examine the usability, acceptability, feasibility, and appropriateness of KeepCalm as primary outcomes. Secondary preliminary efficacy outcomes include clinical decision support success, false positives/negatives of stress alerts, and reduction of challenging behaviors and emotion dysregulation. We will also examine technical outcomes, including the number of artifacts and the proportion of time children are engaged in high physical movement based on accelerometry data, test the feasibility of our recruitment strategies, and test the response rate and sensitivity to change of our measures, in preparation for a future fully powered large-scale randomized controlled trial. RESULTS The pilot trial will begin by September 2023. CONCLUSIONS Results will provide key data on important aspects of implementing KeepCalm in preschools and elementary schools and will provide preliminary data on its efficacy to reduce challenging behaviors and support emotion regulation in children on the autism spectrum. CLINICALTRIAL ClinicalTrials.gov ID: NCT05277194 (https://www.clinicaltrials.gov/ct2/show/NCT05277194)

Objective: Emotion regulation (ER) is a multi-faceted and dynamic process relevant to both normative emotional development and transdiagnostic emotional dysfunction for a range of psychological disorders. There has been tremendous growth in ER research over the past decade, including the development of numerous new measures to assess ER. This Evidence Base Update included a systematic review to identify self- and informant-report questionnaire measures of ER for children and adolescents, including measures of ER strategies and effectiveness (or emotion dysregulation).Methods: PubMed, PsycInfo, and Health and Psychosocial Instruments databases were searched using the terms emotion OR affect AND regulation OR control OR reactivity OR response, as well as terms related to questionnaires and psychometrics, restricted to articles on youth (< 18 years old). Each measure's psychometrics was evaluated based on modified criteria by De Los Reyes and Langer (2018).Results: Nine-hundred ninety-seven papers were identified yielding 87 measures that met inclusion for review. Although the majority (60%) of identified ER measures could not be recommended based on these criteria, 8% were Excellent, 14% were Good, and 17% were Adequate. The recommended measures included: 11 general ER measures (5 focused on strategies, 5 focused on dysregulation/ effectiveness), 13 measures of ER as it relates to specific emotions or contexts such as irritability or peer stress (4 focused on strategies, 9 focused on dysregulation/effectiveness), and 11 measures of other constructs that include an ER subscale (all focused on dysregulation). Conclusions: The characteristics, strengths, and weaknesses of the recommended ER measures are described in order to guide measure selection for clinical or research uses. A synthesis of themes identified during this review includes commonly observed areas of weakness and gaps in the literature to provide a foundation for future research and measure development.

Research indicates that children with autism spectrum disorder (ASD) frequently exhibit dysregulation, which refers to poorly coordinated affective, behavioral, and cognitive responses to a given situation. We examined the characteristics of dysregulation in children presenting to a multidisciplinary ASD clinic for an ASD diagnostic evaluation. Sixty percent of children presenting for an ASD evaluation exhibited dysregulation. Dysregulation prevalence was higher in children without ASD versus with ASD (69% versus 56%). Severe dysregulation was higher in children without ASD (29% versus 16%). Both groups with severe dysregulation were equally likely to be taking psychiatric medications, however, children with ASD were less likely to be receiving therapy. These findings highlight the importance of implementing dysregulation screening and treatment protocols in ASD centers.

This article provides a comprehensive review of emotion dysregulation (ED) in individuals with autism spectrum disorder (ASD). The authors describe ED from a developmental perspective, and highlight how aberrations in social development and a restricted-repetitive repertoire of behaviors, render individuals with ASD more vulnerable to ED. The article also summarizes how ED in children and adolescents with ASD has been measured and conceptualized in research and clinic settings. Evidence-based pharmacologic and cognitive behavioral interventions targeting ED in ASD are summarized, with a focus on how such approaches are tailored to the developmental needs of individuals with ASD.

Emotion regulation (ER) is the ability to modify arousal and emotional reactivity to achieve goals and maintain adaptive behaviors. ER impairment in autism spectrum disorder (ASD) is thought to underlie many problem behaviors, co-occurring psychiatric symptoms, and social impairment, and yet is largely unaddressed both clinically and in research. There is a critical need to develop ER treatment and assessment options for individuals with ASD across the life span, given the multitude of downstream effects on functioning. This article summarizes the current state of science in ER assessment and treatment and identifies the most promising measurement options and treatments.

Autism is more widely recognized and diagnosed than ever before, due in part to broadened diagnostic criteria, heightened awareness of the condition in popular media, and improved early identificat...

Emotional reactivity (e.g. explosive outbursts, tantrums) is a common but understudied challenge for individuals with autism spectrum disorder. Prior research has relied primarily on questionnaire data or observations of very young children. The current study coded emotional reactivity and recovery during a series of standardized frustration tasks in a sample of psychiatrically hospitalized youth with autism spectrum disorder ( N = 150; mean age: 12.76) inclusive of the full spectrum of intellectual and functional abilities and explored relationships between emotional reactivity and participant characteristics. The amount, intensity, and duration of negative affect and total range of affect significantly increased from a baseline period to frustration tasks and significantly decreased during recovery. Younger children displayed more negative affect overall; however, age did not moderate change in affect from baseline to frustration tasks or recovery. Adaptive functioning and verbal ability both moderated change in affect, with individuals with lower adaptive functioning and minimally verbal individuals displaying greater reactivity and less recovery. Reactivity was unrelated to non-verbal IQ, overall autism symptom severity, and parent-reported psychiatric/behavioral problems. The results highlight the feasibility and importance of examining emotional reactivity in more severely affected individuals and suggest the need to develop more targeted interventions for emotional reactivity in this group. Lay Abstract Large emotional reactions (e.g. outbursts, tantrums) can be common and distressing in the lives of individuals with autism spectrum disorder and their families. Most previous research that has examined these types of emotional responses have used questionnaire data or focused only on young children. In addition, very little research has included individuals across a large range of intellectual and functional abilities or individuals with more severe emotional and/or behavioral difficulties. This study examined emotional reactions to frustrating tasks in 6–21-year-olds with autism spectrum disorder who were psychiatrically hospitalized due to emotional and/or behavioral difficulties. We describe change in the amount, intensity, duration, and range of emotional reactions that the participants displayed from a neutral activity to the frustrating tasks and then to a neutral recovery period. We also examined associations between characteristics of the participants and these emotional reactions. We found that younger children displayed more negative emotions across the neutral and frustrating tasks; however, age did not relate to how big their reactions to frustration were. Furthermore, we found that individuals with fewer adaptive skills (i.e. age-appropriate life skills) and minimally verbal individuals had bigger reactions and recovered less following the frustration tasks. The results highlight the importance of examining emotional reactions in individuals with lower verbal and adaptive abilities and for interventions to consider the connection between verbal and adaptive skills and emotional reactions.

Emotion dysregulation is common in autism spectrum disorder; a better understanding of the underlying neural mechanisms could inform treatment development. The tendency toward repetitive cognition in autism spectrum disorder may also increase susceptibility to perseverate on distressing stimuli, which may then increase emotion dysregulation. Therefore, this study investigated the mechanisms of sustained processing of negative information in brain activity using functional magnetic resonance imaging. We used an event-related task that alternated between emotional processing of personally relevant negative words, neutral words, and a non-emotional task. A priori criteria were developed to define heightened and sustained emotional processing, and feature conjunction analysis was conducted to identify all regions satisfying these criteria. Participants included 25 adolescents with autism spectrum disorder and 23 IQ-, age-, and gender-matched typically developing controls. Regions satisfying all a priori criteria included areas in the salience network and the prefrontal dorsolateral cortex, which are areas implicated in emotion regulation outside of autism spectrum disorder. Collectively, activity in the identified regions accounted for a significant amount of variance in emotion dysregulation in the autism spectrum disorder group. Overall, these results may provide a potential neural mechanism to explain emotion dysregulation in autism spectrum disorder, which is a significant risk factor for poor mental health. Lay abstract Many individuals with autism spectrum disorder struggle with emotions that are intense and interfering, which is referred to as emotion dysregulation. Prior research has established that individuals with autism may be more likely than individuals who are not autistic to have repetitive thoughts. It is possible that persistent thoughts about negative or distressing stimuli may contribute to emotion dysregulation in autism spectrum disorder. This study aimed to identify areas of the brain with evidence of persistent processing of negative information via functional magnetic resonance neuroimaging. We used a task that alternated between emotional processing of personally relevant negative words, neutral words, and a non-emotional task. Criteria were developed to define heightened and persistent emotional processing, and analyses were conducted to identify all brain regions satisfying these criteria. Participants included 25 adolescents with autism spectrum disorder and 23 typically developing adolescents who were similar to the autism spectrum disorder group in IQ, age, and gender ratios. Brain regions identified as having greater and continued processing following negative stimuli in the autism spectrum disorder group as compared with the typically developing group included the salience network and the prefrontal dorsolateral cortex. These areas have been previously implicated in emotion dysregulation outside of autism spectrum disorder. Collectively, brain activity in the identified regions was associated with parent-reported emotion dysregulation in the autism spectrum disorder group. These results help to identify a potential process in the brain associated with emotion dysregulation in autism spectrum disorder. This information may be useful for the development of treatments to decrease emotion dysregulation in autism spectrum disorder.

The Emotion Dysregulation Inventory (EDI) was designed and validated to quantify emotion dysregulation (ED) in school-age children, with a particular emphasis on capturing ED in youth with ASD. We saw a need to adapt the EDI for use in young children (ages 2-5) given early childhood is a formative time for emotion regulation development. The present study discusses the adaptation process for the EDI-Young Child (EDI-YC), including item refinement/generation and cognitive interviews (N = 10 with ASD), consistent with the Patient-Reported Outcomes Measurement Information System (PROMIS®) methodology. The item bank was piloted in a sample of 2-year-olds with and without ASD (N = 31), which provided initial support for the EDI-YC as a valid and reliable measure.

Neurodevelopmental disorders (NDDs) are conditions that present with brain dysfunction due to alterations in the processes of brain development. They present with neuropsychiatric, cognitive, and motor symptoms. Autism spectrum disorder (ASD) and Fragile X syndrome (FXS) are two of the most common NDDs.Human brain tissue is a scarce resource that is obtained from postmortem donations. In the case of NDDs, specifically autism, the reduced donation rate of brains prevents researchers to investigate its pathology and fine anatomy. The Hispano-American Brain Bank of Neurodevelopmental Disorders (Banco Hispanoamericano de CErebros de trastornos del NEurodesarrollo) or CENE is a large-scale brain bank for neurodevelopmental disorders in Hispano-America and the US. CENE's objectives are to collect and distribute brains of patients with NDDS, with a focus on ASD and FXS, to perform research, promote education of future scientists, and enhance public awareness about the importance of human tissue availability for scientific research on brain function and disease. CENE has thus far established a bilingual system of nodes and teams in several American countries including California-US, Pennsylvania-US, México, Puerto Rico, Colombia, and Dominican Republic. CENE ensures that postmortem NDD samples used in research better match the world's genetic and ethnic diversity. CENE enables and expands NDD brain research worldwide, particularly with respect to ASD and FXS.

From the earliest descriptions, children with autism have been described as presenting with differences in emotional expression and regulation. However, autism spectrum disorder (ASD) diagnostic criteria do not include these emotional differences. More recently, research has begun to investigate the emotional impairments observed in individuals with ASD across the life span, including how it contributes to a range of poor outcomes. Atypical emotion development can be used to differentiate those at risk for ASD from typically developing children. Research has also identified differences in emotional awareness, expression, recognition, and regulation among children and adults with ASD. Priority areas for future research, such as longitudinal studies of emotion dysregulation beginning in early childhood; development of interventions targeting emotion awareness, recognition, and expression; and study and treatment of emotion dysregulation among adults, will be discussed.

Individuals with autism spectrum disorders (ASD) are more likely to have co-occurring psychiatric conditions such as depression and anxiety. Transdiagnostic constructs such as intolerance of uncertainty (IU) and emotion dysregulation (ED) have both been shown to be individually associated with depression and anxiety in those with ASD.The current study examined the relationship between IU and ED, depression, and anxiety in an ED treatment-seeking sample and examined whether ED acts as a mediator between IU-depression and IU-anxiety.We examined baseline scores for 78 adolescents and young adults (12-21 years old) who were participating in an ED treatment. We assessed for correlations between IU, Reactivity and Dysphoria, anxiety, and depression symptoms, and then conducted mediation analyses to determine whether Reactivity and Dysphoria functioned as a mediator in IU- anxiety and IU- depression relationships.Concordant with prior research, ED, IU, anxiety, and depression scores were correlated. Both Reactivity and Dysphoria were found to mediate both IU-depression and IU-anxiety.Findings suggest that ED contributes to how IU affects psychopathology. Furthermore, both IU and ED may be pertinent treatment targets for individuals with depression or anxiety and ASD.

OBJECTIVE: Emotion dysregulation problems are prevalent and disruptive for many with autism spectrum disorder (ASD). This study compared severity and perceived change in emotion dysregulation in youth with and without ASD and probed correlates of emotion dysregulation (including possible two-way interactions) among youth with ASD. METHOD: Participants were drawn from two large online samples (mean age = 12; range: 6–17) with (N = 1323) and without (N = 921) ASD. The study used the Emotion Dysregulation Inventory (EDI), a parent-report measure designed for youth with ASD. The EDI asks parents about current severity and perceived change (i.e. how current severity compares to lifetime severity) in emotion dysregulation, and includes two factors: Reactivity (rapidly escalating, intense negative affect) and Dysphoria (poorly upregulated positive affect, general unease). RESULTS: Results indicated that youth with ASD had greater Reactivity severity and also greater positive change in Reactivity than non-ASD peers. Furthermore, differences between youth with and without ASD in the relationship between Reactivity and Dysphoria suggest a distinct profile of emotion dysregulation in ASD. Within the ASD sample, age and severity of stereotyped behavior predicted Reactivity and Dysphoria severity and Reactivity change. Female gender, lower parent education, and fluent verbal ability were additional predictors of increased Reactivity severity, while intellectual disability predicted lower Dysphoria severity. CONCLUSIONS: This study provides new insight into predictors of emotion dysregulation in youth with ASD and represents a first step towards identifying which children with ASD may be most vulnerable to severe emotion dysregulation problems.

Evidence suggests increased rates of suicidality in autism spectrum disorder (ASD), but the research has rarely used comparison samples and the role of emotion dysregulation has not been considered. We compared the prevalence of parent-reported suicidality ideation and considered the role of emotion dysregulation in 330 psychiatric inpatient youth with ASD, 1169 community youth with ASD surveyed online, and 1000 youth representative of the US census. The prevalence of suicidal ideation was three and five times higher in the community and inpatient ASD samples, respectively, compared to the general US sample. In the ASD groups, greater emotion dysregulation was associated with suicidal ideation. Implications include consideration of emotion regulation as a potential mechanism and treatment target for suicidality in ASD.

Although more than one in 10 youth with Autism Spectrum Disorder (ASD) is admitted to a psychiatric facility before they reach adulthood, the inpatient population is underrepresented in research. Furthermore, Black youth are more likely to be psychiatrically hospitalized, compared to their White counterparts. Yet, prior research has been inconsistent in potential racial differences in ASD symptoms and severity. This study examined differences in the symptom presentation of psychiatrically hospitalized Black and White youth with ASD. Researchers collected data as part of a larger study of youth admitted to one of six US specialized inpatient psychiatric units between 2013 and 2017. We used bivariate and multivariate models to analyze the data. The study included 654 youth diagnosed with ASD, with an average age of 13 years. While bivariate analyses found that Black youth had lower written language and daily living skills and more impaired social affect and inappropriate speech, multivariate regression models suggested that overall ability level and age may be driving these differences. Specifically, the only variables that significantly predicted adaptive functioning (written language, daily living) and behavioral profiles (social affect, inappropriate speech) were verbal ability, IQ, and age. Race was not a significant predictor in any of the models. Cultural diversity and competency are vital to the identification and treatment of ASD clinical care. Thus, understanding the role race may play in early detection and accurate diagnosis is important to improving ASD identification, diagnosis, and treatment. Autism Res 2020, 13: 532-538. © 2020 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: This study examined differences in autism symptoms between Black and White youth in psychiatric hospitals. We found that while it initially appeared that Black and White youth differed in written language and daily living skills, these racial differences were not significant once we accounted for differences in IQ, age, and verbal ability. Our findings suggest that providers should pay greater attention to other potential reasons for racial disparities in autism services.

OBJECTIVE: The Emotion Dysregulation Inventory (EDI) is an informant questionnaire developed based on the Patient-Reported Outcomes Measurement Information System (PROMIS(®)) Scientific Standards and refined through factor analyses and item response theory (IRT) analyses. Although it was developed to improve measurement of emotion dysregulation in youth with autism spectrum disorder, emotion dysregulation has transdiagnostic significance. Therefore, the aim of this study was to evaluate the EDI’s psychometric properties and to establish IRT-based scores for a general population of youth. METHODS: Data were collected from a sample of 1000 caregivers of 6- to 17-year old youth matched to the US census on age, gender, race/ethnicity, years of education, and region. Confirmatory factor analyses and IRT analyses using the two-parameter graded response model were performed to evaluate the EDI’s structure and psychometric properties. RESULTS: Analyses supported the original two-factor structure of the EDI, reflecting factors for Reactivity and Dysphoria. Simulations of computerized adaptive testing supported use of the same items for a Reactivity short form as those that emerged as most informative in the original autism psychometric analyses. IRT co-calibration with commonly used measures of emotion regulation and irritability in child clinical or community samples indicated the EDI scales provide more information across a wider range of emotion dysregulation. Validity was supported by moderate correlations with measures of related constructs and expected known-group differences. CONCLUSIONS: The EDI is an efficient and precise measure of emotion dysregulation for use in general community and clinical samples as well as samples of youth with ASD.

Social-cognitive challenges in individuals with autism spectrum disorder (ASD) are often assessed using caregiver report or performance-based instruments. This study compared caregiver report and performance-based measures of social cognition to examine convergence. A total of 128 verbal individuals with ASD were administered performance-based tests of social cognition assessing theory of mind, and one family member completed a measure of social cognition. Caregiver reports of social cognition were weakly and not significantly correlated with performance-based test scores. Caregiver- and performance-based measures converged for children compared with adults and for participants with lower intellectual ability. More research is needed to develop social-cognitive measures that incorporate caregiver perspectives and are robust across individuals with ASD of all ages and levels of intellectual functioning.

Unpredictable and potentially dangerous aggressive behavior by youth with Autism Spectrum Disorder (ASD) can isolate them from foundational educational, social, and familial activities, thereby markedly exacerbating morbidity and costs associated with ASD. This study investigates whether preceding physiological and motion data measured by a wrist-worn biosensor can predict aggression to others by youth with ASD. We recorded peripheral physiological (cardiovascular and electrodermal activity) and motion (accelerometry) signals from a biosensor worn by 20 youth with ASD (ages 6-17 years, 75% male, 85% minimally verbal) during 69 independent naturalistic observation sessions with concurrent behavioral coding in a specialized inpatient psychiatry unit. We developed prediction models based on ridge-regularized logistic regression. Our results suggest that aggression to others can be predicted 1 min before it occurs using 3 min of prior biosensor data with an average area under the curve of 0.71 for a global model and 0.84 for person-dependent models. The biosensor was well tolerated, we obtained useable data in all cases, and no users withdrew from the study. Relatively high predictive accuracy was achieved using antecedent physiological and motion data. Larger trials are needed to further establish an ideal ratio of measurement density to predictive accuracy and reliability. These findings lay the groundwork for the future development of precursor behavior analysis and just-in-time adaptive intervention systems to prevent or mitigate the emergence, occurrence, and impact of aggression in ASD. Autism Res 2019, 12: 1286-1296. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Unpredictable aggression can create a barrier to accessing community, therapeutic, medical, and educational services. The present study evaluated whether data from a wearable biosensor can be used to predict aggression to others by youth with autism spectrum disorder (ASD). Results demonstrate that aggression to others can be predicted 1 min before it occurs with high accuracy, laying the groundwork for the future development of preemptive behavioral interventions and just-in-time adaptive intervention systems to prevent or mitigate the emergence, occurrence, and impact of aggression to others in ASD.

Emerging evidence suggests that emotion regulation (ER) impairment in those with ASD is associated with poor mental health. This study used the Emotion Dysregulation Inventory, a new norm-referenced ER measure with clinical cut-offs, developed and validated in ASD and non-ASD samples, to establish rates of ER impairment and understand its association with psychiatric service use in ASD. Parents of 6-17 year olds in three well-characterized samples (nationally representative US n = 1,000; community ASD n = 1,169; inpatient ASD n = 567) completed a battery of questionnaires about their child. The prevalence of ER impairment was significantly higher in the ASD groups compared to the nationally representative sample and highest in the psychiatric Inpatient ASD group. The community ASD and inpatient ASD samples were four and seven times more likely, respectively, to exceed clinical cutoffs for emotional reactivity than the general US sample. Similarly, history of psychiatric hospitalization, recent emergency services use (police contact, emergency room visits, or in-home crisis evaluations for emotional or behavioral concerns in the past 2 months), and psychotropic medication prescriptions were significantly higher in the ASD groups. ER impairment was significantly associated with all forms of psychiatric service use, after controlling for demographics (age, sex, race), co-occurring intellectual disability, and ADHD symptoms. This is the first large-scale study to document substantially higher rates of ER impairment in youth with ASD compared to the general population. The importance of ER impairment is underscored by its association with higher utilization of inpatient, emergency, and medication services in ASD, after accounting for demographics and ADHD-related symptoms.

Emotion regulation (ER) is the ability to modify arousal and emotional reactivity to achieve goals and maintain adaptive behaviors. ER impairment in autism spectrum disorder (ASD) is thought to underlie many problem behaviors, co-occurring psychiatric symptoms, and social impairment, and yet is largely unaddressed both clinically and in research. There is a critical need to develop ER treatment and assessment options for individuals with ASD across the life span, given the multitude of downstream effects on functioning. This article summarizes the current state of science in ER assessment and treatment and identifies the most promising measurement options and treatments.

Therapeutic alliance may influence treatment outcomes for individuals with autism spectrum disorder (ASD). The present study examined the trajectory of alliance, observationally-measured at four timepoints during a 16-week mindfulness-based treatment targeting emotion regulation problems in adolescents and young adults with ASD (n = 37, mean age = 15.28, 78.40% male). Variability in alliance as a function of client characteristics and the degree to which alliance predicted emotion regulation outcomes were assessed using parent-report forms. Results demonstrate that alliance fluctuates throughout treatment. Moreover, stronger alliance predicts decreased dysphoria at posttreatment. Results also suggest that increased ASD symptom severity and depression predict weaker alliance early and throughout treatment. Findings highlight a need for clinicians to consider the importance of developing strong alliance for clients with ASD.

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that is often accompanied by impaired emotion regulation (ER). There has been increasing emphasis on developing evidence-based approaches to improve ER in ASD. Electroencephalography (EEG) has shown success in reducing ASD symptoms when used in neurofeedback-based interventions. Also, certain EEG components are associated with ER. Our overarching goal is to develop a technology that will use EEG to monitor real-time changes in ER and perform intervention based on these changes. As a first step, an EEG-based brain computer interface that is based on an Affective Posner task was developed to identify patterns associated with ER on a single trial basis, and EEG data collected from 21 individuals with ASD. Accordingly, our aim in this study is to investigate EEG features that could differentiate between distress and non-distress conditions. Specifically, we investigate if the EEG time-locked to the visual feedback presentation could be used to classify between WIN (non-distress) and LOSE (distress) conditions in a game with deception. Results showed that the extracted EEG features could differentiate between WIN and LOSE conditions (average accuracy of 81%), LOSE and rest-EEG conditions (average accuracy 94.8%), and WIN and rest-EEG conditions (average accuracy 94.9%).

Youth with autism spectrum disorder are at elevated risk for impaired emotion regulation and clinically impairing anxiety. A prior developmental framework posited that impaired emotion regulation leads to co-occurring psychiatric conditions such as anxiety, with outcome determined in part by autism spectrum disorder–specific moderating factors. Using measures developed and validated in autism spectrum disorder, this study evaluated (1) the association between emotion regulation and anxiety in a large, community-based sample of youth with autism spectrum disorder and a wide range of intellectual and verbal abilities and (2) whether greater core autism spectrum disorder symptoms strengthened the association between impaired emotion regulation and anxiety. Parents of 1107 children with a community diagnosis of autism spectrum disorder (881 boys; age 6–17 years) participated in an online survey assessing their child’s emotion regulation, anxiety, and autism spectrum disorder symptoms. Emotion regulation impairment significantly predicted whether participants had elevated levels of anxiety, after controlling for demographic variables and autism spectrum disorder symptoms; however, there was no interaction of emotion regulation and autism spectrum disorder symptoms. This study is the first to support the anxiety–emotion regulation association with measures developed and validated specifically for autism spectrum disorder, in a large sample with co-occurring intellectual disability and minimally verbal youth with autism spectrum disorder. Lay abstract Many children with autism spectrum disorder have problems with managing their emotions (emotion regulation) and anxiety. In this study, over 1000 parents completed an online survey which showed that emotion regulation and anxiety are closely linked. Although emotion regulation and anxiety are inter-connected, the results also show that autism symptoms play an important role in anxiety in autism spectrum disorder. Emotion regulation problems may be an important target for the treatment of anxiety in autism.

Emotion regulation impairments are common among individuals with autism spectrum disorder and are believed to often underlie commonly seen problems with aggression, depression, and anxiety. The Emotional Awareness and Skills Enhancement program was developed to reduce emotion regulation impairment and thereby improve behavioral disturbance, via mindfulness. Emotional Awareness and Skills Enhancement consists of a 16-week individual therapy treatment targeting emotion regulation impairments among individuals with autism spectrum disorder. We describe the conceptual framework and development of the program and present data on feasibility and preliminary efficacy from a pilot trial. The Emotional Awareness and Skills Enhancement manual was developed using a participatory action framework, based on emotion regulation research specific to autism spectrum disorder and input from individuals with autism spectrum disorder, therapists, and parents of children with autism spectrum disorder. Emotional Awareness and Skills Enhancement was piloted in a two-site open trial with 20 participants with autism spectrum disorder (12-17 years old, confirmed autism spectrum disorder diagnosis, IQ 80).Outcome data support program feasibility and acceptability to participants, as well as significant improvement in emotion regulation impairments and related concerns.Findings offer preliminary support for both the feasibility and clinical effectiveness of the Emotional Awareness and Skills Enhancement program.

Autism spectrum disorder (ASD) is characterized by a variety of social and non-social behavioral deficits. One potential mechanism that could unify this diverse profile of behaviors is slower processing speed. Seventy-six high-functioning adults with ASD were compared to 64 matched controls on standardized measures of processing speed. Participants with ASD were significantly slower on all measures, and on the composite score from the three tests (d’s > .65). ASD participants with slower processing speeds scored higher on the ADOS Communication and Reciprocal Social Interaction scale (r = .34). These findings provide evidence of slower processing speeds in adults with ASD, and that this may be contributing to impairments in social communication skills. Interventions that improve processing speed might improve social communication abilities in ASD.

Limited information about self-injurious behavior (SIB) is known for children and adolescents with Autism Spectrum Disorder (ASD) who require intensive behavioral health interventions. We examined risk-factors for SIB in 302 individuals with ASD (ages 4-20) admitted to six specialized psychiatric inpatient units. Seventy-four percent were reported by a caregiver to display SIB, however, only 25% were observed to engage in daily SIB during hospitalization. Those exhibiting SIB across environments had significantly higher ratings on caregiver questionnaires of SIB severity. Tree-structured classification was used to develop and validate two predictive models, one indicating which inpatient youth with ASD are likely to have SIB and a second indicating which individuals with SIB at home are likely to continue in an inpatient setting.

OBJECTIVE: Cognitive remediation is a promising approach to treating core cognitive deficits in adults with autism, but rigorously controlled trials of comprehensive interventions that target both social and non-social cognition over a sufficient period of time to impact functioning are lacking. This study examined the efficacy of Cognitive Enhancement Therapy (CET) for improving core cognitive and employment outcomes in adult autism. METHOD: Verbal adult outpatients with autism spectrum disorder (N = 54) were randomized to an 18-month, single-blind trial of CET, a cognitive remediation approach that integrates computer-based neurocognitive training with group-based training in social cognition, or an active Enriched Supportive Therapy (EST) comparison focused on psychoeducation and condition management. Primary outcomes were composite indexes of neurocognitive and social-cognitive change. Competitive employment was a secondary outcome. RESULTS: Intent-to-treat analyses indicated that CET produced significant differential increases in neurocognitive function relative to EST (d = .46, P = .013). Both CET and EST were associated with large social-cognitive improvements, with CET demonstrating an advantage at 9 (d = .58, p = .020), but not 18 months (d = .27, p = .298). Effects on employment indicated that participants treated with CET were significantly more likely to gain competitive employment than those in EST, OR = 6.21, p = .023, which was mediated by cognitive improvement. CONCLUSIONS: Cognitive Enhancement Therapy is a feasible and potentially effective treatment for core cognitive deficits in adult autism spectrum disorder. The treatment of cognitive impairments in this population can contribute to meaningful improvements in adult outcomes. LAY SUMMARY: Cognitive Enhancement Therapy (CET), an 18-month cognitive remediation intervention designed to improve thinking and social understanding, was found to be more effective than supportive therapy at improving mental quickness, attention, and employment in adults living with autism. Social understanding was equally improved in CET and supportive therapy. Cognitive remediation interventions are feasible and may confer significant functional benefits to adults with autism. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00902798

Empirically based, consumer-informed programming to support students with Autism Spectrum Disorder (ASD) transitioning to college is needed. Informed by theory and research, the Stepped Transition in Education Program for Students with ASD (STEPS) was developed to address this need. The first level (Step 1) supports high school students and the second level (Step 2) is for post-secondary students with ASD. Herein, we review the extant research on transition supports for emerging adults with ASD and describe the development of STEPS, including its theoretical basis and how it was informed by consumer input. The impact of STEPS on promotion of successful transition into college and positive outcomes for students during higher education is currently being evaluated in a randomized controlled trial.

Identifying modifiable correlates of good quality of life in adults with autism spectrum disorder is of paramount importance for intervention development as the population of adults with autism spectrum disorder increases. This study sought to examine social support and perceived stress as potential modifiable correlates of quality of life in adults with autism spectrum disorder. We hypothesized that adults with autism spectrum disorder without co-occurring intellectual disabilities ( N = 40; aged 18–44 years) would report lower levels of social support and quality of life than typical community volunteers who were matched for age, sex, and race ( N = 25). We additionally hypothesized that social support would buffer the effect of perceived stress on quality of life in adults with autism spectrum disorder. Results indicated that adults with autism spectrum disorder reported significantly lower levels of social support and quality of life than matched typical community volunteers. In addition, findings showed significant direct effects of social support and perceived stress on quality of life in adults with autism spectrum disorder. Social support did not buffer the effect of perceived stress on quality of life. Interventions that teach adults with autism spectrum disorder skills to help them better manage stress and cultivate supportive social relationships have the potential to improve quality of life.

Data from the Autism Inpatient Collection was used to examine the relationship between problem behaviors and verbal ability, which have generally, though not universally, been highly associated. In a comparison of 169 minimally-verbal and 177 fluently-verbal 4 to 20-year-old psychiatric inpatients with ASD, the severity of self-injurious behavior, stereotyped behavior, and irritability (including aggression and tantrums) did not significantly differ, when controlling for age and NVIQ. Verbal ability was not strongly related to the severity of problem behaviors. However, lower adapting/coping scores were significantly associated with increasing severity of each type of problem behavior, even when accounting for verbal ability. Interventions to develop adapting/coping mechanisms may be important for mitigation of problem behaviors across the spectrum of individuals with ASD.

Autism Spectrum Disorder (ASD) is associated with significant healthcare expenditures and a greater utilization of psychiatric health services. High utilization may not be evenly distributed across individuals with ASD. The objective of this study was to identify individual and family characteristics that increase the risk of psychiatric hospitalization. Naturalistic study of two age- and gender-matched ASD cohorts, inpatients enrolled in the Autism Inpatient Collection (AIC) and outpatients enrolled in the Rhode Island Consortium of Autism Research and Treatment (RI-CART), revealed a number of factors associated with hospitalization. Multiple logistic regression analyses revealed that adaptive functioning, ASD symptom severity, primary caregiver's marital status, the presence of mood disorders, and the presence of sleep problems independently increased the risk of psychiatric hospitalization.

This study extends prior memory reports in autism spectrum disorders (ASD) by investigating memory for narratives after longer recall periods and by examining developmental aspects of narrative memory using a cross-sectional design. Forty-seven older children/adolescents with ASD and 31 youth with typical development (TD) and 39 adults with ASD and 45 TD adults were compared on memory for stories from standardized measures appropriate for each age group at three intervals (immediate, 30 min, and 2 day). Both the youth with and without ASD had difficulty with memory for story details with increasing time intervals. More of the youths with ASD performed in the range of impairment when recalling the stories 2 days later as compared to the TD group. The adults with ASD had more difficulty on memory for story details with increasing delay and were poorer at recall of thematic information (needed to create a gist) across the three delay conditions as compared to the TD group. Analyses of the individual results suggested that memory for details of most of the adults with ASD was not impaired when applying a clinical standard; however, a significant percentage of the adults with ASD did not make use of thematic information to organize the narrative information, which would have helped them to remember the stories. The youth with and without ASD performed similarly when both were at a stage of development when memory for details is the primary strategy. The adults with ASD had difficulty with use organizational strategies to support episodic memory. Autism Res 2017, 10: 1523-1532. © 2017 International Society for Autism Research, Wiley Periodicals, Inc.

Mindfulness-based interventions (MBIs) are increasingly popular and have a growing empirical basis of support for improving physical and mental health, general functioning, and quality of life. MBIs are an especially attractive approach to improve emotion regulation (ER) in adolescents who have autism spectrum disorder (ASD), as they are thought to directly target ER and can be tailored to individual needs, symptoms, and cognitive capacity. Despite growing interest in MBIs for adolescents with ASD, there are few clinical delivery resources to support clinicians untrained in the use of mindfulness within therapy. This article uses an ASD-specific MBI as an exemplar to outline common challenges and solutions for clinicians using MBIs with adolescents with ER impairment. Mindfulness teaching practices described in this article have been trialed and refined over several years with >40 participants, across three different sites, and with 16 clinicians from four clinical professional backgrounds-most of whom had no prior experience with MBIs-in the Emotion Awareness and Skills Enhancement (EASE) program trials with adolescents with ASD. Although we describe the use of an MBI program with adolescents with ASD, the suggestions offered herein are relevant to use of MBIs with other clinical populations and include basic strategies for mental health professionals untrained in MBIs to enhance delivery to patients with ER impairment.