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. This special issue of the Journal of Autism and Developmental Disorders (JADD) aims to showcase the most recent research on anxiety in ASD. Around 50% of autistic individuals will experience anxiety that significantly impacts on their daily lives and the lives of their loved ones. When present, anxiety reduces quality of life and interferes with education, employment, and achievement of potential. The urgent need to address this pressing clinical issue was highlighted by the Autistica Priority Setting Partnership (2015), undertaken in collaboration with the autism community in the UK, which identified mental health concerns as the top priority for autism research with specific emphasis on the development of interventions to reduce anxiety identified as amongst the top five research priorities. The idea for this Special Issue arose as a consequence of discussions which took place at the Anxiety and ASD Special Interest Group at the International Meeting for Autism Research in 2015, with the call for papers issued in summer of 2015. We have been privileged to receive very many high quality submissions, all of which have been subjected to standard peer review processes. The outcome of this endeavour is this special issue, comprising 24 excellent papers from the leading international researchers in the field. Our aspiration was to present to JADD readership the most up-to-date scientific and methodological developments in the field. The papers included in this special issue fall into three broad themes: (1) mechanisms and correlates underpinning the development and maintenance of anxiety in ASD, (2) issues with measurement, assessment, and stability of anxiety in ASD, and (3) interventions for anxiety for autistic people

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

Anxiety in autism is an important treatment target because of its consequences for quality of life and wellbeing. Growing evidence suggests that Cognitive Behaviour Therapies (CBT) and Mindfulness-Based Therapies (MBT) can ameliorate anxiety in autism but cost-effective delivery remains a challenge. This pilot randomized controlled trial examined whether online CBT and MBT self-help programmes could help reduce anxiety in 54 autistic adults who were randomly allocated to either an online CBT (n=16) or MBT (n=19) programme or a waitlist control group (WL; n=19). Primary outcome measures of anxiety, secondary outcome measures of broader wellbeing, and potential process of change variables were collected at baseline, after programme completion, and then 3 and 6 months post-completion. Baseline data confirmed that intolerance of uncertainty and emotional acceptance accounted for up to 61% of self-reported anxiety across all participants. The 23 participants who were retained in the active conditions (14 MBT, 9 CBT) showed significant decreases in anxiety that were maintained over 3, and to some extent also 6 months. Overall, results suggest that online self-help CBT and MBT tools may provide a cost-effective method for delivering mental health support to those autistic adults who can engage effectively with online support tools

Anxiety, intolerance of uncertainty and restricted and repetitive behaviour: insights directly from young people with ASD

In order to investigate the experience of anxiety and restricted and repetitive behaviours (RRB) in young people with ASD, 19 families with young people with ASD aged between 13 and 20 years completed questionnaire measures of RRB, anxiety, and intolerance of uncertainty. Ten young people also completed a novel semi-structured interview exploring an individualised example of an RRB. Findings demonstrated that young people with ASD can self-report and show insight in to their RRB, and replicated previous findings based on parent report showing a significant positive relationship between RRB and anxiety. This is the first evidence of young person self-report using both quantitative and qualitative data and indicates a range of reasons why young people may engage in RRB

An investigation into the psychometric properties of the Hospital Anxiety and Depression Scale in patients with breast cancer

BACKGROUND: To determine the psychometric properties of the Hospital Anxiety and Depression Scale (HADS) in patients with breast cancer and determine the suitability of the instrument for use with this clinical group. METHODS: A cross-sectional design was used. The study used a pooled data set from three breast cancer clinical groups. The dependent variables were HADS anxiety and depression sub-scale scores. Exploratory and confirmatory factor analyses were conducted on the HADS to determine its psychometric properties in 110 patients with breast cancer. Seven models were tested to determine model fit to the data. RESULTS: Both factor analysis methods indicated that three-factor models provided a better fit to the data compared to two-factor (anxiety and depression) models for breast cancer patients. Clark and Watson's three factor tripartite and three factor hierarchical models provided the best fit. CONCLUSION: The underlying factor structure of the HADS in breast cancer patients comprises three distinct, but correlated factors, negative affectivity, autonomic anxiety and anhedonic depression. The clinical utility of the HADS in screening for anxiety and depression in breast cancer patients may be enhanced by using a modified scoring procedure based on a three-factor model of psychological distress. This proposed alternate scoring method involving regressing autonomic anxiety and anhedonic depression factors onto the third factor (negative affectivity) requires further investigation in order to establish its efficacy

A systematic review of quality of life of adults on the autism spectrum

Autism spectrum disorder is associated with co-existing conditions that may adversely affect an individual’s quality of life. No systematic review of quality of life of adults on the autism spectrum has been conducted. Our objectives were as follows: (1) review the evidence about quality of life for adults on the autism spectrum; (2) critically appraise current practice in assessing quality of life of adults on the autism spectrum. We searched bibliographic databases and other literature to identify studies using a direct measure of quality of life of adults on the autism spectrum. Hand searching of reference lists, citation searching and personal communication with field experts were also undertaken. In total, 827 studies were identified; 14 were included. Only one quality of life measure designed for use with the general autism spectrum population was identified. Quality of life of adults on the autism spectrum is lower than that of typically developing adults, when measured with tools designed for the general population. There are no comprehensive autism spectrum disorder–specific quality of life measurement tools validated for use with representative samples of adults on the autism spectrum. There is a pressing need to develop robust measures of quality of life of autistic adults

A Measurement Invariance Analysis of the Interpersonal Needs Questionnaire and Acquired Capability for Suicide Scale in Autistic and Non-Autistic Adults.

Background: Autistic adults are more likely to engage in suicidal thoughts and behaviors, but there is little research to explore the underlying reasons. It is unclear whether self-report suicide scales that have been designed for non-autistic people accurately measure suicide risk constructs in autistic people. Therefore, this study explored, for the first time, whether the measurement properties of the self-report scales of the Interpersonal Theory of Suicide are equivalent in autistic and non-autistic adults. Methods: In this study, responses from 342 autistic and 353 non-autistic people on the Interpersonal Needs Questionnaire-10 (INQ-10) and Acquired Capability for Suicide Scale-Fearlessness about Death (ACSS-FAD) were compared by using measurement invariance analysis. Data were gathered through an online cross-sectional survey of the self-report measures. Results: Results suggest that measurement properties of the INQ-10 were different in autistic people. Autistic characteristics, such as different theory of mind and preference for concrete language, may have led the scale items to load differently on the factors in the autistic group than in the non-autistic group. The measurement properties of the ACSS-FAD were invariant between autistic and non-autistic people. Conclusions: Scores on the INQ-10 cannot be meaningfully compared between autistic and non-autistic people due to different measurement properties. Future research could explore how autistic people experience the concepts of burdensomeness and belonging, to consider how measures could accurately capture this. This would allow researchers to explore the role of these constructs in the development of suicidal thoughts and behaviors in autistic people. Clinicians should be aware that suicide risk factors may present differently in autistic people. Scores on the ACSS-FAD can be meaningfully compared, but the negatively worded scale items may pose similar response difficulties to autistic and non-autistic people

Validation of the revised children's Anxiety and Depression Scales (RCADS) and RCADS short forms adapted for adults

Background: The life span nature of anxiety and depression has led to an interest in whether assessments designed for use with children and young people are also valid for adults. The Revised Children’s Anxiety and Depression Scales (RCADS) is a commonly used measure and we aimed to explore its structural validity in adults. Methods: We examined the factorial validity of the original and two short form versions of the Revised Children’s Anxiety and Depression Scales (RCADS) adapted for adults, using confirmatory factor analysis with a convenience sample (n = 371) aged 18-67. Results: All versions of the RCADS were found to provide reliable measures of general anxiety and depression in adults and of most subdimensions of anxiety corresponding to the original version of the RCADS. However, anxiety subdimension reliability was primarily driven by the strong general anxiety dimension, due to the high comorbidity between anxiety subtypes. Limitations: We did not include data for children as well as adults in our analyses and small changes were made to the wording of five RCADS items to make them appropriate for adults. Conclusions: Results suggest that all versions could be helpful for longitudinal and comparative research and evaluation of clinical outcomes, in situations where the focus is on general anxiety and depression, rather than clinical subtypes

Development and validation of the suicidal behaviours questionnaire - autism spectrum conditions in a community sample of autistic, possibly autistic and non-autistic adults

BackgroundAutistic people and those with high autistic traits are at high risk of experiencing suicidality. Yet, there are no suicidality assessment tools developed or validated for these groups.MethodsA widely used and validated suicidality assessment tool developed for the general population (SBQ-R), was adapted using feedback from autistic adults, to create the Suicidal Behaviours Questionnaire—Autism Spectrum Conditions (SBQ-ASC). The adapted tool was refined through nine interviews, and an online survey with 251 autistic adults, to establish clarity and relevance of the items. Subsequently, 308 autistic, 113 possibly autistic, and 268 non-autistic adults completed the adapted tool online, alongside self-report measures of autistic traits (AQ), camouflaging autistic traits (CAT-Q), depression (PHQ-9), anxiety (ASA-A), thwarted belongingness and perceived burdensomeness (INQ-15), lifetime non-suicidal self-injury, and the original version of the suicidality assessment tool (SBQ-R). Analyses explored the appropriateness and measurement properties of the adapted tool between the groups.ResultsThere was evidence in support of content validity, structural validity, internal consistency, convergent and divergent validity, test–retest validity, sensitivity and specificity (for distinguishing those with or without lifetime experience of suicide attempt), and hypothesis testing of the adapted tool (SBQ-ASC) in each group. The structure of the SBQ-ASC was equivalent between autistic and possibly autistic adults, regardless of gender, or use of visual aids to help quantify abstract rating scales.LimitationsThe samples involved in the development and validation of the adapted tool were largely female, and largely diagnosed as autistic in adulthood, which limits the generalisability of results to the wider autistic population. The SBQ-ASC has been developed for use in research and is not recommended to assess risk of future suicide attempts and/or self-harm. The SBQ-ASC has been designed with and for autistic and possibly autistic adults, and is not appropriate to compare to non-autistic adults given measurement differences between these groups.ConclusionsThe SBQ-ASC is a brief self-report suicidality assessment tool, developed and validated with and for autistic adults, without co-occurring intellectual disability. The SBQ-ASC is appropriate for use in research to identify suicidal thoughts and behaviours in autistic and possibly autistic people, and model associations with risk and protective factors

Cognitive Risk Factors of Social Anxiety

This study aimed to examine a model of cognitive risk factors, which were Fear of Negative Evaluation, Intolerance of Uncertainty and Shame in predicting social anxiety. Furthermore, this study also aimed to investigate any possible interactions among those factors in predicting social anxiety. Of 112 participants, nearly one half of whom were university students, completed a series of online questionnaires. Hierarchical regression via SPSS version 21.0 to examine the relative contribution of IU and interaction analyses using PROCESS macro for SPSS to investigate any possible interactions were performed. IU and FNE each consistently predicted social anxiety whilst shame unexpectedly did not. An interaction between IU and FNE was detected. These findings extend our understanding of the critical role of FNE and IU in predicting social anxiety and interestingly, FNE and IU strengthen each other in predicting social