Short report: Recommendations for education, clinical practice, research, and policy on promoting well-being in autistic youth and adults through a positive focus on sexuality and gender diversity.

LAY ABSTRACT: In this article, we propose recommendations on what we can do to promote that autistic people can enjoy their sexuality and gender identity, because that contributes to overall well-being.First, we briefly summarize the existing research on sexuality and gender diversity in autistic individuals.Next, we propose recommendations for how to promote sexual and gender diversity-related health and well-being. Based on what is known about sexuality, gender diversity, and relationships in autistic adolescents and adults, we convened an international group of autistic and non-autistic researchers, advocates, parents, and professionals to develop recommendations to promote sexual and gender health in autistic people.The resulting recommendations were checked through an online survey distributed to autistic people across the world. The online participants endorsed the importance of eight final recommendations related to:1. Providing education and information on sexuality, relationships, and gender diversity to autistic individuals and their families;2. Improving expertise in and accessibility to healthcare for sexuality, relationships, and gender-related questions, with specific attention to prevention of and support after sexual victimization; and3. Meaningfully including the autism community in future research that addresses well-being relating to sexuality, relationships, and gender diversity.These community-driven recommendations aim to promote sexual health and well-being in autistic individuals internationally.

Understanding the experiences and needs in autism education: A semi-structured interview among Chinese American parents of autistic children.

Background and Aims: The diversity of the autistic population seeking professional services and education in the United States has increased. As the diagnosis of autism increases among the Chinese American immigrant population, there is also an increasing need to learn about this population and provide appropriate intervention and education for this group. However, current education and intervention provided for autistic individuals tend to be culturally blind. Gaps were found in our understanding of the cultural context and its relationship with the education mechanisms among Chinese American autistic families. The current study intends to investigate how Chinese American parents perceive the education materials and intervention strategies received by their autistic children as well as their experiences and needs in the education process. Method: Semi-structured interviews were conducted among 10 Chinese American parents (one father and nine mothers) online. They all had children who had a formal diagnosis of autism spectrum disorder and received some intervention or education. Thematic analysis was used to analyse the results. Results: The study suggested that most Chinese American parents were satisfied with the current education materials and intervention strategies provided to their autistic children. Due to cultural-related stigma, parents differ in their perceptions of children's autism diagnosis and characteristics as well as their expectations of children's culturally sensitive education. A theoretical model was created to provide culture-centered interpretation of the interconnected relationship between their pre- and post-immigration contexts and parenting attitudes. Conclusions: Culture plays a critical role in understanding Chinese American parents' experiences, needs, and expectations of culturally sensitive education for their autistic children. Interconnected relationships were found between contexts and parenting attitudes, which were largely influenced by cultural-related stigma. Implications: Suggestions and implications were provided for institutions and professionals working with Chinese American families and children. It is critical for them to learn about the experiences, needs, and attitudes of Chinese American parents to provide Chinese American autistic children with more appropriate and culturally sensitive education.

Psychometric Properties of Psychosexual Functioning Survey Among Autistic and Non-autistic Adults: Adapting the Self-Report Teen Transition Inventory to the U.S. Context.

Psychosexual functioning is an important aspect of human development and relationships. A previous study investigated psychosexual functioning of autistic adolescents using the Teen Transition Inventory (TTI), but there is a lack of comprehensive measurement of psychosexual functioning among autistic and non-autistic (NA) adults. To address this gap, the current study adapted the self-report TTI to the Psychosexual Functioning Survey (PSFS) and presented it to 131 autistic (n = 59) and NA adults (n = 72) in the U.S. Comparisons of psychometric properties between the original TTI and the PSFS are shared; the developmental relevancy among some items was changed, and the alphas indicated a difference in the content of certain scales. Differences emerged between autistic and NA adults in both the intra- and interpersonal domains of psychosexual functioning, but not in sexual and intimate behaviors. The findings suggest the persistence of differences from adolescence to adulthood between autistic and NA people and highlight the importance of understanding the unique experiences of adults in psychosexual functioning relative to diagnostic status.

Adapting the Tackling Teenage Training Sex Education Program for Autistic Adults in the US: A Pilot Study.

Despite the established need for sexuality and relationship programming for autistic adults, there are extremely limited curricula for this population. This pilot study used an evidence-based sexuality and relationship education program for autistic adolescents (Tackling Teenage Training) as the basis for an adult-focused virtual psychoeducational group. Qualitative feedback, quantitative ratings of the programming, and behavioral surveys from participants were collected. Nine participants completed the program, and corresponding pre and post measures. Highly rated topics, for example gender identity and online dating, were consistent with previous research on what autistic adults want from a sexuality and relationship education program. Future programming should incorporate increased attention to themes and topics highlighted by participants, and should utilize the teaching tools (e.g., role play, peer discussions) identified as useful by the participants.

Topics and timing of sexuality and relationship education for autistic and non-autistic adults in the United States.

INTRODUCTION: Sexuality and relationship education is a learning area that historically has been overlooked, especially for autistic individuals. To inform future programming, we are in need of evidence-based reasoning to guide program design, such as what to cover and when. In particular, the social aspects of sexuality and relationship education, which are less commonly addressed, need further scrutiny. OBJECTIVE: To identify sexuality and relationship education priorities and timelines based on feedback from autistic and non-autistic adults. METHODS: An online anonymous survey of adults in the United States posed questions about sexuality and relationship education, sexual and relationship experiences, and autistic traits. RESULTS: Comparisons by diagnostic group (autistic and non-autistic) revealed no significant differences in the timing of sexual experiences. Autistic individuals were significantly more likely to indicate that they wanted to learn more about gender identity, sexual orientation, consent, and assertiveness than non-autistic peers. However, the majority of all participants across diagnostic groups wanted more information across all surveyed topics. CONCLUSIONS: Lack of differences in timing of sexuality-related experiences highlights the importance of beginning sexuality and relationship education early for all learners. Important diagnostic group differences highlight critical areas of development for sexuality and relationship education programming. The importance of incorporating needs of autistic learners into program design is highlighted for future work. Overall findings support the idea that more sexuality and relationship education across the lifespan would best meet the learning needs of all people.

Frustration, Cognition, and Psychophysiology in Dysregulated Children: A Research Domain Criteria Approach.

OBJECTIVE: Dysregulated children experience significant impairment in regulating their affect, behavior, and cognitions and are at risk for numerous adverse sequelae. The unclear phenomenology of their symptoms presents a barrier to evidence-based diagnosis and treatment. METHOD: The cognitive, behavioral, and psychophysiological mechanisms of dysregulation were examined in a mixed clinical and community sample of 294 children ages 7-17 using the Research Domain Criteria constructs of cognitive control and frustrative nonreward. RESULTS: Results showed that caregivers of dysregulated children viewed them as having many more problems with everyday executive function than children with moderate or low levels of psychiatric symptoms; however, during standardized assessments of more complex cognitive control tasks, performance of dysregulated children differed only from children with low symptoms on tests of cognitive flexibility. In addition, when frustrated, dysregulated children performed more poorly on the Go/No-Go Task and demonstrated less autonomic flexibility as indexed by low respiratory sinus arrhythmia and pre-ejection period scores. CONCLUSION: The findings of this study suggest that autonomic inflexibility and impaired cognitive function in the context of frustration may be mechanisms underlying childhood dysregulation.

Brief Report: Sources of Sexuality and Relationship Education for Autistic and Neurotypical Adults in the U.S. and a Call to Action.

Sexuality and relationship education (SRE) occurs in many formats. In order to inform best practices, current trends of SRE sources must be characterized. Using an online survey of autistic and neurotypical adults in the United States, we compared eleven potential sources of SRE across nine content areas. Source use did not differ significantly across five of the content areas. Same-aged peers were consulted less often by the autistic adults for flirting, dating, and consent. For partnered sexual behavior, neurotypical adults reported consulting romantic partners significantly more often than autistic adults. Across all groups, use of the internet as a source of information was high. The need for improving SRE access based on existing trends is discussed.

Me looking at you, looking at me: The stare-in-the-crowd effect and autism spectrum disorder.

INTRODUCTION: The stare-in-the-crowd (SITC) effect describes the ability to detect self-directed gaze in a crowd. Given the importance of gaze detection in initiating and maintaining social interactions, there is a need to better characterize the SITC effect. METHODS: Autistic and neurotypical young adults were presented with four SITC conditions. Eye tracking outcomes and arousal were compared by diagnosis and condition using repeated measures analysis of variance. Hierarchical regression was used to explore behavioral measures. RESULTS: Significant interaction of diagnosis and condition was found for eye tracking outcomes. Overall, autistic participants exhibited less looking than neurotypical participants. Interest area dwell time, fixation count, and second fixation duration were significantly higher for conditions with shifting gaze, as well as conditions with more self-directed gaze across participants. Two hierarchical regression models of gaze behaviors with advanced theory of mind as a predictor were significant. DISCUSSION: Autistic individuals respond to various gaze conditions in similar patterns to neurotypical individuals, but to a lesser extent. These findings offer important targets for social interventions.

Brief Report: Me, Reporting on Myself: Preliminary Evaluation of the Criterion-Related Validity of the Theory of Mind Inventory-2 when Completed by Autistic Young Adults.

There is a need for increased understanding of self-report measures for autistic individuals. In this preliminary study, we examine how a theory of mind self-report relates to other self-report measures for groups of autistic and neurotypical individuals, as well as eye tracking outcomes. Expected patterns of relatedness emerged between self-reports and the eye tracking findings, which lends validity to the theory of mind measure. Self-report measures are critical for autistic individuals to share their own experiences and this is the first step in establishing a theory of mind self-report tool.

Tracking the Influence of Autistic Traits on Competencies Among School Aged Children with Subthreshold Autistic Traits: A Longitudinal Study.

This study aims to further explore the implications of autism spectrum disorder (ASD) symptoms for children who do not meet full diagnostic criteria. More specific characterization of how challenges present relative to traits of ASD such as social responsiveness is vital to developing an understanding of what competency and mental health difficulties these impairments are related to, and if they persist over time. Assessments of autistic traits, clinical symptomotology, and competency were used to quantify the relation of these domains cross-sectionally and across time. Social Responsiveness Scale (SRS) scores significantly contributed to a teacher-report Happy scale from the Teacher's Report Form and a parent-report Social scale from the Child Behavior Checklist. No significant longitudinal models emerged. Splitting the SRS scores into three severity classes revealed that impaired social responsiveness is significantly related to competency, unlike average or below average deficits. Implications of subthreshold ASD traits on competency outcomes are discussed.

Response bias and response monitoring: Evidence from healthy older adults and patients with mild Alzheimer's disease.

Patients with Alzheimer's disease (AD) often exhibit an abnormally liberal response bias in recognition memory tests, responding "old" more frequently than "new." Investigations have shown patients can to shift to a more conservative response bias when given instructions. We examined if patients with mild AD could alter their response patterns when the ratio of old items is manipulated without explicit instruction. Healthy older adults and AD patients studied lists of words and then were tested in three old/new ratio conditions (30%, 50%, or 70% old items). A subset of participants provided estimates of how many old and new items they saw in the memory test. We demonstrated that both groups were able to change their response patterns without the aid of explicit instructions. Importantly, AD patients were more likely to estimate seeing greater numbers of old than new items, whereas the reverse was observed for older adults. Elevated estimates of old items in AD patients suggest their liberal response bias may be attributed to their reliance on familiarity. We conclude that the liberal response bias observed in AD patients is attributable to their believing that more of the test items are old and not due to impaired meta-memorial monitoring abilities.

Temperamental Characteristics of Withdrawn Behavior Problems in Children.

Withdrawn/depressed behavior (WD) as defined by the Child Behavior Checklist (CBCL) relates to various outcomes in developmental psychopathology such as depression, pervasive developmental disorders, and suicide. We sought to examine the temperamental characteristics of children who concurrently endorse symptoms of WD. Junior Temperament and Characteristic Inventory (JTCI) and CBCL data were collected from 397 children's parents in a family study in the northeastern United States. Linear mixed models were used to test the relations between WD and temperament dimensions (Novelty Seeking, Harm Avoidance, Reward Dependence, Persistence) on the JTCI, while controlling for age, sex, item overlap, and co-occurring aggression and attention problems. When controlling for definitional artifact and CBCL aggressive behavior and attention scores, high harm avoidance and low reward dependence were both significant predictors of childhood withdrawn behavior. This study marks the first characterization of a temperamental profile associated with WD in children and adolescents.

Disruptive Mood Dysregulation Disorder at Ages 13-18: Results from the National Comorbidity Survey-Adolescent Supplement.

OBJECTIVE: "Disruptive mood dysregulation disorder" (DMDD) has been introduced into the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. but the utility of this new label and the clinical correlates of the children it describes are yet to be determined. METHODS: A proxy for the DMDD diagnosis was extracted from the National Comorbidity Survey - Adolescent Supplement (NCS-A) data on 6483 adolescents (51.4% female) including Composite International Diagnostic Interview (CIDI) diagnoses and measures of impaired functioning from the Sheehan Disability Scale. Cross tabulations and logistic regression were used to assess for prevalence and comorbidity. RESULTS: A total of 310 (5.26%) adolescents met the criteria for DMDD when diagnostic hierarchy and frequency of outbursts were not considered. At the low end of prevalence estimation, only nine adolescents (0.12%) met the most stringent proxy diagnosis, and they also met criteria for a number of comorbid disorders and functional impairment. The rates of comorbidity and functional impairment in adolescents with bipolar disorder were the same, irrespective of their meeting criteria for DMDD. CONCLUSIONS: The DMDD diagnosis captures a small group of adolescents with multiple other psychiatric and neurologic conditions. The specificity of this diagnostic label, therefore, at least in adolescents, remains an open question.

Child Temperament, Maternal Parenting Behavior, and Child Social Functioning.

We examined child temperament, maternal parenting, and the effects of their interactions with each other on child social functioning. A total of 355 children aged 5-18 years old (54% male; mean age=10.8) were evaluated. Regression equations were used to test models of the main and interactive effects of temperament and maternal parenting behavior on the Social Problems and Social Competence Subscales of the Child Behavior Checklist (CBCL), a questionnaire assessing internalizing and externalizing behavior problems in children ages 4 to 18. Higher levels of child Novelty Seeking and Harm Avoidance and lower levels of Persistence were significantly associated with poorer social functioning. When accounting for child temperament, neither maternal parenting nor the interaction between maternal parenting and child temperament were significantly associated with social functioning. However, the interaction between maternal positive involvement and harm avoidance trended toward significance, such that at higher levels of harm avoidance, more extreme levels of maternal positive involvement were related to lower levels of social functioning. Further research on the interplay between child temperament and parenting across different stages of development is warranted.

Measuring the stare-in-the-crowd effect: a new paradigm to study social perception.

Social perceptual ability plays a key role in successful social functioning. Social interactions demand a number of simultaneous skills, one of which is the detection of self-directed gaze. This study demonstrates how the ability to accurately detect self-directed gaze, called the stare-in-the-crowd effect, can be studied using a new eye-tracking paradigm. A set of images was developed to test this effect using a group of healthy undergraduate students. Eye movements and pupil size were tracked while they viewed these images. Participants also completed behavioral measures about themselves. Results show that self-directed gaze results in significantly more looking by participants. Behavioral predictors of gaze behaviors were not identified, likely given the health of the sample. However, correlations with variables are reported to explore in future research.

Candidate gene associations with withdrawn behavior.

BACKGROUND: Social withdrawal is a core neuropsychiatric phenomenon in developmental psychopathology. Its presence predicts psychopathology across many domains, including depression, psychosis, autism, anxiety, and suicide. Withdrawn behavior is highly heritable, persistent, and characteristically worsens without intervention. To date, few studies have successfully identified genetic associations with withdrawn behavior, despite the abundance of evidence of its heritability. This may be due to reliance of categorical over dimensional measures of the behaviorally inhibited phenotype. The aim of this study is to identify associations between known psychiatric candidate genes and a dimensionally derived measure of withdrawn behavior. METHODS: Genetic information was collected on 20 single-nucleotide polymorphisms (SNPs) from a custom-designed SNP chip and TAQMAN arrays of 4 variable number of tandem repeat (VNTR) genes for 551 individuals from 187 families. Linear mixed modeling was employed to examine the relationship between genotypes of interest and Child Behavior Checklist (CBCL) Withdrawn Behavior Subscale Score (WBS) while controlling for gender and age through multiple linear regressions. RESULTS: Withdrawn behavior was highly associated with polymorphism rs6314 of the serotonin receptor 2A (HTR2A) [p = .009, estimate = 0.310 (bootstrap 95% CI 0.155-0.448), bootstrap p = .001] and rs1800544 of the alpha 2-adrenergic (ADRA2A) [p = .001, estimate = -0.310 (bootstrap 95% CI -0.479 to -0.126), bootstrap p = .001] genes after correction for gender and age. The association between withdrawn behavior and ADRA2A was stronger for younger children. CONCLUSIONS: HTR2A and ADRA2A genes are associated with withdrawn behavior. This reinforces the role of catecholaminergic genes in the heritability of withdrawn behavior.

Temperamental profiles of dysregulated children.

It is crucial to characterize self-regulation in children. We compared the temperamental profiles of children with the Child Behavior Checklist (CBCL) Dysregulation Profile (CBCL-DP) to profiles associated with other CBCL-derived syndromes. 382 children (204 boys; aged 5-18) from a large family study were examined. Temperamental profiles were based on the Juvenile Temperament and Character Inventory. Children with the CBCL-DP had a temperamental profile characterized by high Novelty Seeking, high Harm Avoidance, low Reward Dependence and low Persistence. Linear mixed models and regression-based models demonstrated that the CBCL-DP was associated with a "disengaged" temperamental profile. This profile is similar to the profile seen in adult disorders of self-regulation, including cluster B personality disorders. These results support the hypothesis that the CBCL-DP measures poor self-regulation.