Associations between autistic traits, depression, social anxiety and social rejection in autistic and non-autistic adults.

Autistic people frequently experience negative judgements from non-autistic people, often fuelled by misconceptions that autistic people lack empathy. Understanding responses to negative social judgement among autistic people is crucial because of the potential negative impact on wellbeing and future interactions. We investigated the role of autistic traits, social anxiety, and depression on behavioural indices of social rejection in 20 autistic (AUT; 11 males) and 40 non-autistic (N-AUT; 21 males) university students. Participants completed the Social Judgement Task (SJT) where they predicted whether they were liked by another person, then received feedback on whether those evaluations were correct. Participants also completed an Age Judgement Task (AJT) where they estimated the age of the pictured person. The AUT group had lower positive expectation scores, meaning less tendency to predict being liked. Across the whole sample, higher social anxiety predicted greater tendency to anticipate rejection from others, not autistic traits. These findings suggest early experiences of rejection might lead to a negative self-bias in autistic people and emphasise the importance of using a transdiagnostic approach by showing that social anxiety rather than autistic traits is associated with expectation of social rejection.

Binocular rivalry in autistic and socially anxious adults.

Background: Social anxiousness is a pervasive symptom in both social anxiety disorder and autism spectrum conditions. Binocular rivalry, which occurs when different images are presented to each eye, has been used to explore how visual and cognitive processing differs across various clinical diagnoses. Previous studies have separately explored whether individuals with autism or anxiety experience binocular rivalry in ways that are different from neurotypical individuals. Methods: We applied rivalry paradigms that are similar to those used in previous studies of autism and general anxiety to individuals experiencing symptoms of social anxiousness at clinical or subclinical levels. We also incorporated rivalrous stimuli featuring neutral and emotional facial valances to explore potential overlap of social processing components in social anxiety and autism. Results: We hypothesized that higher levels of social anxiousness would increase binocular rivalry switch rates and that higher levels of autistic traits would decrease switch rates. However, stimulus condition did not affect switch rates in either diagnostic group, and switch rate was not significantly predictive of dimensional measures of either autism or social anxiety. Discussion: This may suggest a common mechanism for atypical visual cognition styles previously associated with social anxiety and autism. Alternatively, differences in switch rates may only emerge at higher trait levels than reported by the participants in our studies. Furthermore, these findings may be influenced by sex differences in our unique sample.

Understanding the heterogeneity of anxiety in autistic youth: A person-centered approach.

The present study aimed to examine anxiety profiles among children and adolescents on the autism spectrum. It further aimed to characterize the association between the identified anxiety profiles and key clinical and developmental variables. The Spence Children's Anxiety Scale-Parent Version (SCAS-P) data from a large international pooled sample of 870 caregivers of autistic children and adolescents (Mage  = 11.6 years, SDage  = 2.77; 107 females) was used. Latent profile analysis identified a three-anxiety profile solution exhibiting high entropy (0.80) and high latent profile probabilities, with good classification accuracy. Identified profiles fell along the severity spectrum and were named as the mild (n = 498), moderate (n = 272) and severe (n = 100) anxiety profiles. There were no statistically significant differences between the three anxiety profiles in terms of sex distribution. Participants in the mild profile were significantly younger than those in the severe profile, had significantly fewer social communication difficulties than youth in the moderate anxiety profile group and had significantly fewer restricted and repetitive behaviors and lower cognitive functioning scores compared to participants in moderate and severe anxiety profiles. This is the first study to move beyond identifying associations and group-level differences to exploring and identifying characteristics of anxiety-based subgroups at an individual level that differ on key clinical and developmental variables. The subgroups identified in this study are a preliminary, yet important, first step towards informing future assessment and individualized interventions aiming to support young people on the autism spectrum to reduce and manage anxiety. LAY SUMMARY: This study tried to understand if there are subgroups of autistic young people who may have similar anxiety profiles. We found that we could meaningfully group young people into three groups based on how severe the anxiety symptoms their caregivers reported were: a group with low levels of anxiety, those with moderate anxiety, and those with more severe anxiety. We also found that the young people in the mild group were younger, had fewer autism traits and lower levels of intellectual functioning than young people in the other two groups.

Sensory Sensitivity and Intolerance of Uncertainty Influence Anxiety in Autistic Adults.

Several models of anxiety in autistic adults have focused on the role of intolerance of uncertainty which has biological and evolutionary bases, as a cognitive explanation for the high prevalence of anxiety in autism. This framework suggests that all people are born with a healthy level of intolerance of uncertainty, and as we develop, this intolerance is lessened as we learn when situations are safe and begin to understand and manage the uncertainty. This process of learning about managing uncertainty does not happen in the same way in those who are high in autistic traits, which could be the reason for the high levels of anxiety symptoms commonly seen in this population. We examined archival data of 199 non-autistic and 55 autistic adults from prior studies in which we collected self-report measures of autistic traits, intolerance of uncertainty, sensory processing, and anxiety. We conducted two path analyses to examine the role of intolerance of uncertainty in anxiety in autistic adults. The first model tested the idea that intolerance of uncertainty, an evolutionary phenomenon common for all people, could explain some of the cognitive aspects of anxiety in autism. The second model suggests that primary neurodevelopmental differences associated with autistic traits underlie the sensory sensitivity and sensory seeking behaviors, which in turn increase intolerance of uncertainty and subsequent anxiety. We found that the "neurodevelopmental" model had better model fit than the "evolutionary stress" model, suggesting that the neurodevelopmental impact of higher levels of autistic traits could moderate a non-autistic trajectory of learning to manage uncertainty as children develop and understand that uncertainty is common and acceptable.

"Intolerance of uncertainty" mediates the relationship between social profile and anxiety in both Williams syndrome and autism.

Anxiety is the most significant mental health concern for both Williams syndrome (WS) and autism. Whilst WS and autism are characterized by some syndrome-specific social differences, less is known about cross-syndrome profiles of anxiety symptoms. Previous research has shown that Intolerance of Uncertainty (IU) is a core mechanism of anxiety maintenance for clinically anxious populations and for autistic children, adolescents, and adults. The only published study in this area for WS has shown some similar patterns-with an added emphasis on the role of sensory sensitivities-in a sample of older teens and adults (mean age = 24), with the authors highlighting the need for younger samples to consider developmental influences. Here we report a cross-syndrome, cross-sectional mediation analyses of children diagnosed with WS or autism, including data from parent surveys of 90 children with WS (n = 48) or autism (n = 42). Group differences showed higher trait levels on all measures for the autism group. Importantly, the relationship between social profile and anxiety was fully mediated by IU level for both groups. This suggests possible similar core mechanisms underlying anxiety in these conditions, and the possibility of generalized intervention approaches especially related to managing distress related to uncertainty in multiple contexts. LAY SUMMARY: Autism and Williams Syndrome share some similarities in social profile and also in anxiety traits, but there are also some key differences as well. Comparing them side-by-side at the same time improved identification of ways to reduce feelings of anxiety. We found that the intolerance of uncertainty affected the relationship between social profile and anxiety in the same way for young children diagnosed with autism or Williams syndrome, meaning that intervention approaches could be similar for both.

Dissociating the effect of reward uncertainty and timing uncertainty on neural indices of reward prediction errors: A reward positivity (RewP) event-related potential (ERP) study.

Accurate reward predictions include forecasting both what a reward will be and when a reward will occur. We tested how variations in the certainty of reward outcome and certainty in timing of feedback presentation modulate neural indices of reward prediction errors using the reward positivity (RewP) component of the scalp-recorded brain event-related potential (ERP). In a within-subjects design, seventy-three healthy individuals completed two versions of a cued doors task; one cued the probability of a reward outcome while the other cued the probability of a delay before feedback. Replicating previous results, RewP amplitude was larger for uncertain feedback compared to certain feedback. Additionally, RewP amplitude was differentially associated with uncertainty of presence/absence of reward, but not uncertainty of feedback timing. Findings suggest a dissociation in that RewP amplitude is modulated by reward prediction certainty but is less affected by certainty surrounding timing of feedback.

Validity of the WISC-V in Youth with Autism Spectrum Disorder: Factor Structure and Measurement Invariance.

Objective: Assessment of intellectual abilities in individuals with autism spectrum disorder (ASD) is a core component of a comprehensive diagnostic evaluation. However, relatively limited information is available regarding the validity of one of the most commonly-used measures of intelligence, the Wechsler Intelligence Scale for Children - 5th Edition (WISC-V) in ASD.Method: We investigated the factor structure and measurement invariance of the WISC-V in a sample of 349 children aged 6-16 diagnosed with ASD using single- and multi-group confirmatory factor analysis. The comparison group was the WISC-V standardization sample.Results: A four-index bifactor solution best fit the ASD group data. Measurement invariance analyses indicated support for configural and metric, but not scalar, invariance of the published 5-index structure, suggesting systematic differences in performance among some subscales in ASD. The 7-subtest FSIQ scale had partial scalar invariance after relaxing equality constraints on the Coding and Digit Span subtest intercepts, suggesting sources other than theorized IQ ability contribute to lower scores on these subtests within ASD. The Cognitive Proficiency Index (CPI) failed to demonstrate appropriate fit in baseline models. The General Ability Index (GAI) had full configural, metric, and scalar invariance.Conclusions: Statistical bias on the WISC-V within ASD in processing speed and working memory subtests creates significant limitations for the use of FSIQ and especially CPI index scores in ASD populations. The GAI showed strong measurement properties and should be considered as the preferred indicator of overall intellectual functioning when assessing children with ASD using the WISC-V.

Predicting Parent Reactions at Diagnostic Disclosure Sessions for Autism.

Receiving a diagnosis of autism for their child can be a pivotal moment for parents, yet there is little research about how providers can predict parent reactions and adjust their feedback. We investigated factors related to parent reactions during the disclosure session using interviews with providers (n = 6), a parent focus group (n = 10), and a mixed-methods survey of parents (n = 189) of recently diagnosed children. Parents' prior knowledge of autism and anxiety about diagnosis predicted emotional reactions and readiness for next steps. Families anxious about receiving a diagnosis are most in need of information but may leave the session feeling lost and unprepared. Providers can promote positive emotional reactions for parents and prevent confusion by increasing their own positivity, warmth, respect, clarity, and confidence.

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.

Looking good but feeling bad: "Camouflaging" behaviors and mental health in women with autistic traits.

LAY ABSTRACT: Women who try to hide or "camouflage" their autistic traits are likely to report that they feel distressed, think of suicide, and/or struggle to function in everyday life. We asked 58 women with autistic traits to complete questionnaires about camouflaging and mental health. Most of these women did not have a formal diagnosis of autism, yet a majority reported that they camouflaged autistic traits, and a large majority reported significant mental health challenges. Some researchers have suggested that women with autistic traits are more likely than autistic men to experience mental health challenges because women may try more to "fit in" socially by camouflaging their autistic traits. Analyses showed that camouflaging was associated with feeling distressed (depressed, anxious, and/or stressed). For women who reported above-average levels of camouflaging, camouflaging was also associated with having thoughts about suicide and struggling to function in everyday life. Trying to camouflage autistic traits was associated with mental health challenges, regardless of whether those traits were very mild or more severe. The findings of this study may influence how mental health professionals evaluate and treat women with autistic traits.

Self-guided mindfulness and cognitive behavioural practices reduce anxiety in autistic adults: A pilot 8-month waitlist-controlled trial of widely available online tools.

LAY ABSTRACT: Anxiety in autism is an important target for psychological therapies because it is very common and because it significantly impacts upon quality of life and well-being. Growing evidence suggests that cognitive behaviour therapies and mindfulness-based therapies can help autistic individuals learn to manage feelings of anxiety but access to such therapies remains problematic. In the current pilot study, we examined whether existing online cognitive behaviour therapy and mindfulness-based therapy self-help tools can help reduce anxiety in autistic adults. Specifically, 35 autistic adults were asked to try either an existing online cognitive behaviour therapy (n = 16) or mindfulness-based therapy (n = 19) programme while a further 19 autistic adults served as a waitlist comparison group. A first important finding was that 23 of the 35 (66%) participants who tried the online tools completed them, suggesting that such tools are, in principle, acceptable to many autistic adults. In addition, adults in the cognitive behaviour therapy and mindfulness-based therapy conditions reported significant decreases in anxiety over 3 and to some extent also 6 months that were less apparent in the waitlist group of participants. On broader measures of mental health and well-being, the benefits of the online tools were less apparent. Overall, the results suggest that online self-help cognitive behaviour therapy and mindfulness-based therapy tools should be explored further as a means of providing cost-effective mental health support to at least those autistic individuals who can engage effectively with such online tools.

Anxiety in young people with autism spectrum disorder: Common and autism-related anxiety experiences and their associations with individual characteristics.

Anxiety is common in autism spectrum disorder. Many anxiety symptoms in autism spectrum disorder are consistent with Diagnostic and Statistical Manual of Mental Disorders (5th ed.) anxiety disorders (termed "common" anxieties), but others may be qualitatively different, likely relating to autism spectrum disorder traits (herein termed "autism-related" anxieties). To date, few studies have examined both "common" and "autism-related" anxiety experiences in autism spectrum disorder. We explored caregiver-reported Spence Children's Anxiety Scale-Parent version data from a multi-site (United Kingdom, Singapore, and United States) pooled database of 870 6- to 18-year-old participants with autism spectrum disorder, of whom 287 provided at least one written response to the optional open-ended Spence Children's Anxiety Scale-Parent item 39 ("Is there anything else your child is afraid of?"). Responses were thematically coded to explore (a) common and autism-related anxiety presentations and (b) their relationship with young people's characteristics. Nearly half of the responses were autism-related anxieties (mostly sensory, uncommon, or idiosyncratic specific phobias and worries about change and unpredictability). The other half described additional common anxieties not covered in the original measure (mostly social, weather and environmental disasters, and animals). Caregivers of participants who were more severely affected by autism spectrum disorder symptoms reported more autism-related, as compared to common, additional anxieties. Implications for the assessment and understanding of anxiety in autism are discussed.

Separate contributions of autistic traits and anxious apprehension, but not alexithymia, to emotion processing in faces.

Reduced eye fixation has been commonly reported in autistic samples but may be at least partially explained by alexithymia (i.e., difficulty understanding and describing one's emotional state). Because anxiety is often elevated in autism, and emotion-processing differences have also been observed in anxious samples, anxiety traits may also influence emotion processing within autism. This study tested the contribution of dimensional traits of autism, anxious apprehension, and alexithymia in mediating eye fixation during face processing. Participants included 105 adults from three samples: autistic adults (AS; n = 30), adults with clinically elevated anxiety and no autism (HI-ANX; n = 29), and neurotypical adults without elevated anxiety (NT; n = 46). Experiment 1 used an emotion identification task with dynamic stimuli, while Experiment 2 used a static luminance change detection task with emotional- and neutral-expression static photos. The emotions of interest were joy, anger, and fear. Dimensional mixed-effects models showed that autism traits, but not alexithymia, predicted reduced eye fixation across both tasks. Anxious apprehension was negatively related to response time in Experiment 1 and positively related to eye fixation in Experiment 2. Attentional avoidance of negative stimuli occurred at lower levels of autism traits and higher levels of worry traits. The results highlight the contribution of autism traits to emotional processing and suggest additional effects of worry-related traits.

Functional MRI connectivity of children with autism and low verbal and cognitive performance.

Background: Functional neuroimaging research in autism spectrum disorder has reported patterns of decreased long-range, within-network, and interhemispheric connectivity. Research has also reported increased corticostriatal connectivity and between-network connectivity for default and attentional networks. Past studies have excluded individuals with autism and low verbal and cognitive performance (LVCP), so connectivity in individuals more significantly affected with autism has not yet been studied. This represents a critical gap in our understanding of brain function across the autism spectrum. Methods: Using behavioral support procedures adapted from Nordahl, et al. (J Neurodev Disord 8:20-20, 2016), we completed non-sedated structural and functional MRI scans of 56 children ages 7-17, including LVCP children (n = 17, mean IQ = 54), children with autism and higher performance (HVCP, n = 20, mean IQ = 106), and neurotypical children (NT, n = 19, mean IQ = 111). Preparation included detailed intake questionnaires, video modeling, behavioral and anxiety reduction techniques, active noise-canceling headphones, and in-scan presentation of the Inscapes movie paradigm from Vanderwal et al. (Neuroimage 122:222-32, 2015). A high temporal resolution multiband echoplanar fMRI protocol analyzed motion-free time series data, extracted from concatenated volumes to mitigate the influence of motion artifact. All participants had > 200 volumes of motion-free fMRI scanning. Analyses were corrected for multiple comparisons. Results: LVCP showed decreased within-network connectivity in default, salience, auditory, and frontoparietal networks (LVCP < HVCP) and decreased interhemispheric connectivity (LVCP < HVCP=NT). Between-network connectivity was higher for LVCP than NT between default and dorsal attention and frontoparietal networks. Lower IQ was associated with decreased connectivity within the default network and increased connectivity between default and dorsal attention networks. Conclusions: This study demonstrates that with moderate levels of support, including readily available techniques, information about brain similarities and differences in LVCP individuals can be further studied. This initial study suggested decreased network segmentation and integration in LVCP individuals. Further imaging studies of LVCP individuals with larger samples will add to understanding of origins and effects of autism on brain function and behavior.

Priorities for Advancing Research on Youth with Autism Spectrum Disorder and Co-occurring Anxiety.

Research on anxiety disorders in youth with autism spectrum disorder (ASD) has burgeoned in the past two decades. Yet, critical gaps exist with respect to measuring and treating anxiety in this population. This study used the nominal group technique to identify the most important research priorities on co-occurring anxiety in ASD. An international group of researchers and clinicians with experience in ASD and anxiety participated in the process. Topics ranked as most important focused on understanding how ASD symptoms affect treatment response, implementing treatments in real world settings, developing methods to disentangle overlapping symptoms between anxiety and ASD, and developing objective measures to assess anxiety. Collectively, these priorities can lead to collaborative studies to accelerate research in the field.

Psychophysiological Arousal and Auditory Sensitivity in a Cross-Clinical Sample of Autistic and Non-autistic Anxious Adults.

Many autistic people report overwhelming sensory experiences and also elevated levels of anxiety. Understanding how these experiences are linked to each other can contribute to improved support and intervention for reducing sensory overload and anxiety. This study included 95 young adult participants including autistic adults, non-autistic adults reporting to a psychotherapy clinic with high levels of anxiety, and neurotypical adults with no psychiatric concerns. We measured pupil size using including a baseline task with no auditory stimulus followed by two blocks of simple auditory habituation. In a subset of 80 participants we also measured self-report levels of sensory processing, anxious apprehension, and intolerance of uncertainty. The autism group showed atypical sensory processing on all four measured domains of the Adolescent and Adult Sensory Profile including sensory sensitivity, sensory seeking, sensory avoidance, and low registration subscales. Dimensional analyses across all participants showed significant positive correlations between sensory sensitivity, sensory seeking, and sensory avoidance domains with scores from the Intolerance of Uncertainty Scale-Short Form and Penn State Worry Questionnaire. The autism group showed significantly larger pupil size than other groups at baseline, before any auditory stimulation. There were no group differences in the rate of auditory habituation, nonetheless the overall, absolute larger pupil size remained in the autism group throughout the experiment. We suggest that this and other findings could indicate chronic hyperarousal in many autistic people. Treatment for anxiety in autism should be informed by knowledge of unique aspects of anxiety in autism and consider the role of sensory experience and everyday psychophysiological arousal.

Anxiety and ASD: Current Progress and Ongoing Challenges.

Symptoms of anxiety add significant burden to many autistic individuals and their loved ones. There is an urgent need for better understanding of the unique underlying mechanisms of anxiety in ASD, and for the development of more specific assessment methods and treatment recommendations. This special issue brings together 24 articles grouped into three themes; mechanisms, measurement, and intervention. The result is a review of current anxiety research in ASD that is both broad and deep. Key themes include recognition of the importance individual differences in aetiology and presentation of anxiety in ASD, the need for a more nuanced understanding of the interactions between anxiety and characteristics of ASD and the need to develop appropriately adapted treatments.

Relationship between brain stem volume and aggression in children diagnosed with autism spectrum disorder.

BACKGROUND: Aggressive behaviors are common in individuals diagnosed with autism spectrum disorder (ASD) and may be phenotypic indicators of different subtypes within ASD. In current research literature for non-ASD samples, aggression has been linked to several brain structures associated with emotion and behavioral control. However, few if any studies exist investigating brain volume differences in individuals with ASD who have comorbid aggression as indicated by standardized diagnostic and behavioral measures. METHOD: We examined neuroimaging data from individuals rigorously diagnosed with ASD versus typically developing (TD) controls. We began with data from brain volume regions of interest (ROI) taken from previous literature on aggression including the brainstem, amygdala, orbitofrontal cortex, anterior cingulate cortex, and dorsolateral prefrontal cortex. We defined aggression status using the Irritability subscale of the Aberrant Behavior Checklist and used lasso logistic regression to select among these predictor variables. Brainstem volume was the only variable shown to be a predictor of aggression status. RESULTS: We found that smaller brainstem volumes are associated with higher odds of being in the high aggression group. CONCLUSIONS: Understanding brain differences in individuals with ASD who engage in aggressive behavior from those with ASD who do not can inform treatment approaches. Future research should investigate brainstem structure and function in ASD to identify possible mechanisms related to arousal and aggression.

Inter-trial Coherence of Medial Frontal Theta Oscillations Linked to Differential Feedback Processing in Youth and Young Adults with Autism.

BACKGROUND: Impairment in prediction and appreciation for choice outcomes could contribute to several core symptoms of ASD. We examined electroencephalography (EEG) oscillations in 27 youth and young adults diagnosed with autism spectrum disorder (ASD) and 22 IQ-matched neurotypical controls while they performed a chance-based reward prediction task. METHOD: We re-analyzed our previously published ERP data (Larson et al., 2011) and examined theta band oscillations (4-8 Hz) at frontal midline sites, within a timing window that overlaps with the feedback-related negativity (FRN). We focused on event-related changes after presentation of feedback for reward (WIN) and punitive (LOSE) outcomes, both for spectral power and inter-trial phase coherence. RESULTS: In our reward prediction task, for both groups, medial frontal theta power and phase coherence were greater following LOSE compared to WIN feedback. However, compared to controls, inter-trial coherence of medial frontal theta was significantly lower overall (across both feedback types) for individuals with ASD. Our results indicate that while individuals with ASD are sensitive to the valence of reward feedback, comparable to their neurotypical peers, they have reduced synchronization of medial frontal theta activity during feedback processing. CONCLUSIONS: This finding are consistent with previous studies showing neural variability in ASD and suggest that the processes underlying decision-making and reinforcement learning may be atypical and less efficient in ASD.